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The Journal of 
Bone and Joint Surgery 

The Official Publication of the 
AMERICAN ORTHOPAEDIC ASSOCIATION 
BRITISH ORTHOPAEDIC ASSOCIATION 
AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS 

Owned and published by the American Orthopaedic Association 


•Wfc** •• • • 

VOLUME XX 

OLD SERIES - VOLUME XXXVI 


1938 


8 THE FENWAY, BOSTON, MASSACHUSETTS, U. S. A. 




The Journal of 
Bone and Joint Surgery 

The Official Pnhlication oj the 
American Orthopaedic Association 
British Orthopaedic Association 
American Academy of Orthopaedic Surgeons 
Owned and published by the American Orthopaedic Association 
♦Title registered in United States Patent Office 


VOL. XX, No. 1 


January, 1938 


Old Series 

VOL. XXXVI. No. 4 


Editor, E. G. Brackett, M.D. Assistant Editor, Florence L. Daland 
BOARD OF ASSOCIATE EDITORS 
Z. B. Adams, M.D. Leo Mayer, M.D. 

Murray S. Danforth, M.D. Charles F. Painter, M.D. 

H. Osmond Clarke, M.B., F.R.C.S., British Editorial Secretary, 

5, Holly Bank, Victoria Park, Manchester, England 

EDITORIAL COMMITTEE 

John L. Porter, M.D., Treasurer, 636 Church Street, Evanston, Illinois 
Ralph K. Ghormley, M.D., Secretary, The Mayo Clinic, Rochester, Minnesota 
W. W. Plummer, M.D., President-Elect, 89 Bryant Street, Buffalo, New York 
E. P. Brockman, F.R.C.S., Secretary, 73, Harley Street, London, W. I. 

Published quarterly: January, April, July, and October 
8 THE FENWAY, BOSTON, MASSACHUSETTS 

Original Articles. — Papers for publication will be accepted only for 
exclusive publication in this Journal. The American Orthopaedic Association 
does not officially endorse the opinions presented in the different papers pub- 
lished in this Journal. 

(f Copyright. — Material appearing in The Journal is covered by copy- 
right, but, as a general rule, no objection will be made to the reproduction in 
reputable medical journals of anything in these pages, provided that per- 
mission is obtained from The Journal and that proper credit is given. 

(( Advertisements. — Advertising rates will be furnished on application. 

(f Change of Address. — In sending change of address, both the old 
and new addresses should be given, (f The Subscription Price of this Jour- 
nal is $5.00 per year, payable in advance, for the United States and such 
other countries as, under the revised postal regulations, are subject to 
domestic rates; $5.25 for Canada; the equivalent of $5.75 for all other 
foreign countries included in the postal union. Single copies of current issue 
$1.50. (f Checks, drafts, and post-office money-orders should be made 
payable to The Journal of Bone and Joint Surgery. 

Address all Communications to the Editor 

THE JOURNAL OF BONE AND JOINT SURGERY 

8 The Fenway, Boston, Massachusetts, U. S. A. 


TABLE OF CONTENTS 


PACK 

Scoliosis Treated by the Wedging Jacket. Selection oe the Area to I^e Inured, 


By Felix L. Butte, M.D., New York, N. Y 1 

Tuberculous Osteitis of the Ischium. 

By Ragnar Magmisson, M.D., BorSs, Sweden 23 


Acute Hematogenous Osteomyelitis. 

By D. E. Robertson, M.D., Toronto, Ontario, Canada 35 

A Histopathological Study of the Synovial Membra.ve with Mucicarmine Staini.vg, 

Bj"^ James H. Cherry, M.D., and Ralph K. Ghormlcy, M.D., Rochester, Minnesota 48 


Tendon Transplantation for Clawing of the Great Toe. 

By M. F. Forrester-Brown, M S., M.D., Batli, Somerset, England 57 


Chondrodysplasia (Ollier’s Disease). A Report of a Case Resembling Osteitis Fibrosa 
Cystica. 

By George H. Sanderson, M.D., Stockton, California, and M.D., San 

Francisco, California .ROwtK i . .'I'r'r.'V! Gl 


A Review of Synovectomy. 

B 3 ’' Paid P. Sweit, M.D., Hartford, Connecticut 


S. 


' CoWsjDi 



68 


II 


The Evolution of the Ivnee Joint. W 0 A J 

By Maurice H. Hcrzmark, M.D., New Yor^j^P .1 • Kjj ^ . 

Spinal Fixation. A Method of Bending THPfiaavFr*— — 

By Gawad Hamada, M.R.C.S., Alexandria, Egj’^pt S5 


Intracapsular Fracture of the Neck of the Femur. Case Report and Pathological Study. 


By Laurence Jones, M.D., and B. Albert Lieberman, Jr., M.D., Kansas Citj', Missouri 88 

Reconstruction Operations for Old Ununited Fractures of the Neck of the Femur. 

B}' E. G. Brackett, M.D., Boston, Massachusetts 93 


Comments on Internal Fixation in Fresh Fractures of the Neck of the Femur. 

By IF. TF. Plummer, M.D., Buffalo, New York 97 


Closed Reduction of Fractures of the Neck of the Femur. 

Bjf Guy TF. Leadbetter, M.D., Washington, D. C 108 


Experiences with Internal Fixation in Fresh Fractures of the Neck of the Femur. 

Bj'' R. I. Harris, F.R.C.S., Toronto, Ontario, Canada lU 

Dashboard Dislocation of the Hip. A Report of Twenty Cases of Traumatic Dislocation. 

By Robci't V. Funstcn, M.D., Prentice Einser, M.D., and Charles J. Frankel, M.D., Universitj', 

^ Virginia 124 

The Spastic Hand. 

By Michael S. Burman, M.D., New York, N. Y 133 


Spastic Intrinsic-Muscle Imbalance of the Foot. Resection of the Motor Branch of the 


Lateral Plantar Nerve for Intrinsic-Muscle Contracture. 

Bi' M jehad S. Burman, M.D., New York, N. Y 14a 


The Role of the Discus Articularis in Colle.s’ Fracture. 

Bj- Granllrij )F. Taylor, M.D., and C. Langdon Parsons, M.D., Boston, Massachusetts 149 


{Continued on page 13) 



TAIiLE OF CONTENTS 


(Continued) 

PAGE 


Ossification ok the Tendo Achileis. 

By John 11'. Gliormlry, M.D., Alliany, New York 153 

Intua-Aiiticueau Displacement ok the Inteiinae Epicondyee Foeeo wing Dislocation. 

By Alexonder P. Aiikcn, M.D., Boston, Massachusetts, and Harold M. Childress, M.D., Dallas, 

Texas 161 

The Use of Amniotic-Fluid Concentrate in Orthopaedic Conditions. y 

Bj’ Mandril Shiinherg, M.D., Wadsworth, Kansas 1671.,^^ 

Fractures of the Metacarpaes. A New Method of Reduction and Immobiliz.ation. 

By S. A. Jahss, M.D., New York, N. Y 178 

Ad.asiantinoma of Tiria. Report of a Case. 

By Donald J. Rchhock, M.D., and C. G. Barber, M.D., Cleveland, Ohio 187 

Tendon Transposition. An End-Result Study. 

By Charles ll'". Peabody, M.D., Detroit, Michigan 193 

Skeletal Traction in Fractures of the Radius and the Ulna. 

By Eugene L. Jewett, M.D., Orlando, Florida 206 

Osteomyelitis of the Patella. Report of Two Cases. 

By R. J. Dittrich, M.D., Fort Scott, Kansas 209 

Friction versus Traction. A Simple .Appliance for Use in Making Traction to the Head. 

By Albert H. Freiberg, M.D., Cincinnati, Ohio 213 

A Case of Primary Bacillus-Pyocyaneus Arthritis in an Infant. 

By ir. A. Bishop, Jr., M.D., Cincinnati, Ohio 216 

A Special Bone Retractor for Subtalar Arthrodesis. 

By William H. von Lackum, M.D., New York, N. Y 219 

A New Knife for Use in Removing Semilunar Cartilages. 

By Frank A. Lowe, M.D., San Francisco, California, and Louis TF. Break, M.D., El Paso, Texas 220 

Peroneal-Nerve Palsy Dub to Compression by Adhesive Plaster. 

By Seth Selig, M.D., New York, N. Y 222 

An Adaptation of the Balkan Frame for Developing Motion and Abduction of the Hip. 

By Phul L. Norton, M.D., and Fred Ilfeld, M.D., Boston, Massachusetts 224 

A Traction Apparatus for Fractures of Both Bones of the Forearm. 

By Edwai-d N. Reed, M.D., Santa Monica, California 227 

New Technique in the Treatment of Fractures of the Forearm. 

By Lelio Zeno, M.D., Rosario, Argentine Republic 229 

The Importance of E.arly Diagno.sis in the Treat.ment of Slipping Femoral Epiphysls. 

(Correction.) 

By Leo Mayer, M.D., New York, N. Y 230 

Percy Willard Roberts 231 

Edward Sparh A WK Hatch 231 

News Notes 232 

Current Literature o.}o 


13 





FRACTURES* 


Every Surgeon and Physiologist knows these to be very 
numerous. Experimentalists have determined that meta- 
bolic influences such as the endocrines and diet ore much 
more important than had been previously supposed.* Such 
fundamental physiological processes as the activity of the 
enzyme phosphatase have been studied in order to give 
the Surgeon the advantage of better facilities.! 

From the research department of Austenal Laboratories has 
come VITALLIUMf which, fashioned into nails, screws, 
plates and other metallic appliances used in open reduc- 
tion, gives the Surgeon the kind of solid fixation he requires 
with a cobalt-chromium alloy— coinp/efely inert in the 
tissues, as reported by Venable and his associates. ! No 
later irritating chemical or physical inflammatory effects 
to defeat the ends of clever surgery. / 

Write for details. Scientific reprints or detailed information 
will be gladly sent on request from your supply house or 


AUSTENAL LABORATORIES, Inc. 

34 West 33rd Street 5932 Wentworth Avenue 

New York City Chicago, 111. 

*Lindsay and Howes, Jr. Bone & Joinl Surg.. 13:491, 1931.' 

TRADE MARK Downs and McKeown, Arch. Surg,, 25:94 & 108, 1932. 

REG U S PAT OFF '“‘t Robinson, Biochem. Jour., 17:28, 1923. 

tVenable el al. Trans. Southern Surg. Assoc. Vol., 49. 1937. 



14 


In nnswrrinK advertisements please mention The Journal of Bone and Joint Surgery 



The Journal of 
Bone and Joint Surgery 

The Official Publication oj the 
American Orthopaedic Association 
British Orthopaedic Association 
American Academy of Orthopaedic Surgeons 
Owoed and published by the American Orthopaedic Association 
•Title registered in United States Patent Office 


VOL. XX, No. 2 


April, 1938 


Old Series 

VOL. XXXVI, No. 2 


Editor, E. G. Brackett, M.D. Assistant Editor, Florence L. Daland 

board of associate editors 

Z. B. Adams, M.D. Leo Mayer, M.D. 

Murray S. Danforth, M.D. Charles F. Painter, M.D. 

Fi. Osmond Clarke, M.B., F.R.C.S., British Editorial Secretary, 

5, Holly Bank, Victoria Park, Manchester, England 

EDITORIAL COMMITTEE 

John L. Porter, M.D., Treasurer, 636 Church Street, Evanston, Illinois 
Ralph K. Ghor.mley, M.D., Secretary, The Mayo Clinic, Rochester, Minnesota 
W. W. PLUNn>tER, M.D., President-Elect, 89 Bryant Street, Buffalo, New York 
E. P. Brockman, F.R.C.S., Secretary, 73, Harley Street, London, W. 1. 

Published quarterly; January, April, July, and October 
8 THE FENWAY, BOSTON, MASSACHUSETTS 

(f Original Articles. — Papers for publication will be accepted only for 
exclusive publication in this Journal. The American Orthopaedic Association 
does not officially endorse the opinions presented in the different papers pub- 
lished in this Journal. 

C[ Copyright. — Material appearing in The Journal is covered by copy- 
right, but, as a general rule, no objection will be made to the reproduction in 
reputable medical journals of anything in these pages, provided that per- 
mission is obtained from The Journal and that proper credit is given. 

(f Advertisements. — Advertising rates will be furnished on application. 

(f Change of Address. — In sending change of address, both the old 
and new addresses should be given. (I[ The Subscription Price of this Jour- 
nal is $5.00 per year, payable in advance, for the United States and such 
other countries as, under the revised postal regulations, are subject to 
domestic rates; $5.25 for Canada; the equivalent of $5.75 for all other 
foreign countries included in the postal union. Single copies of current issue 
$1.50. (f Checks, drafts, and post-office money-orders should be made 
payable to The Journal of Bone and Joint Surgery. 


Address all Communications to the Editor 

THE JOURNAL OF BONE AND JOINT SURGERY 

8 The Fenway, Boston, Massachusetts, U. S. A. 


TABLE OF CONTENTS 


' PAGE 

The President’s Address. A Plea for the Fundamental Principles of Orthopaedic 
Surgery. 

By A . Bruce Gill , M . D ., Philadelphia, Pennsjdvania 2G3 

r Opposition of the Thumb. 

By Sterling Bunnell , M . D ., San Francisco, California 269 

Diseases of the Apophyseal (Intertortebral) Articulations. 

By Albert Oppenhehner , M . D ., Beirut, Sj'ria 285 

An Operation to Improve Function in Quadriceps Paralysis. 

By Carl C . Yount , M . D ., Pittsburgh, Pennsylvania 314 

“Spondylodesis”. The Use of the Short Bone Graft in Fusion of the Tuberculous Spine. 

By J . de Mol van Otterloo , M . D ., ’s-Gravenhage, Netherlands 320 

Enlargement of the Ligamentum Flavum. A Cause of Low-Back Pain with Sciatic 
Radiation. 

By Howard A . Brown , M . D ., San Francisco, California 325 

A Procedure for the Correction of Internal Rotation of the Thigh in Spa.stic Paralysis. 

By Herbert A . Durham , M . D ., Shreveport, Louisiana 339 

Experimental Non-Calcification of Callus Simulating Non-Union. 

By A . IF. Ham , M . B ., F . F . Tisdall , M . D ., and T . G . H . Drake , Jl/.R., Toronto, Ontario, Canada 345 

Pneumoroentgenography of the Knee Joint. An Analysis of Fifty Cases. 

By Paul A . Quaintance , AI . D ., Los Angeles, California 353 

Posterior Hernia of the Knee Joint. A Cause of Internal Der.^ngement of the Knee. 

By G . E . Haggart , M . D ., Boston, Massachusetts • 363 

Flange Osteotomy for the Correction of Knees Ankylosed in Flexion. 

By Henry Briggs , M . D ., Newark, New Jersey 374 

The Treatment of Slipping of the Upper Femoral Epiphysis with Minimal Displacement. 

By PhiUp D . Wilson , M . D ., New York, N. Y 379 

Lateral Introduction of the Screw-Bolt in Intracapsular Fracture of the Hip. 

By Myron 0 . Henry , M . D ., Minneapolis, Minnesota 400 

Correction of Scoliosis by a Distractor Apparatus. 

By John Donaldson , M . D ., Elizabethtown, Pennsylvania, and 0. Anderson Engh , il/.D., Wash- 
ington, D. C 405 

Treatment of Localized Fibrocystic Cavities in Bone by Curettage and Packing with 
Bone Chips. 

Bj" Walker E . Surift , M . D ., and Halford Hallock , M . D ., New York, N. Y 411 

Subcutaneous Tenotomy of the Achilles Tendon. 

By John T . Hodgen , M . D ., and Charles H . Frantz , M . D ., Grand Rapids, Michigan 419 

Non-Union of Fractures of the Carpal Navicular. 

Bj' Benjamin E . Obletz , M . D ., Buffalo, New York, and Bernard , il/. Halbstein , M . D ., Cincinnati, 

Ohio 424 

Tensile Strength of the Anterior Longitudinal Ligament in Relation to Treatment 
OF 132 Crush Fractures of the Spine. 

By Arthur G . Davis , M . D ., Erie, Pennsylvania 429 

Cellulose-Compound Casts Used in the Treatment of Arthritis. 

By Robert J . Joplin , M . D ., Boston, Massachusetts 439 

The Neurological Aspects of Injuries to the Spine. 

By Howard C . A ' affziger , M . D ., San Francisco, California 444 


{Continued on page 13) 



TABLE OF CONTENTS 


(Continued) 

PAGE 

Ak Accessouy Tadlv: Tor \Vmcii Eliminates Guesswork from Extra-Articular Internal 
Fix,\tion or Femoral-Neck Fractures. 

By E. IF. Cleary, M.D., San Francisco, California 449 

Carpometacarpal Dislocations. Report of a Case. 

By Howard li. Sliorbc, Oklahoma City, Oklahoma 454 

Compound Disloc.^tion of the Talus without Malleol.^r Fracture. 

By John Paul Horlh, M.D., Philadelpliia, Pennsylvania 458 

Hip Fractures. Valgus Position — Accidental or Engineered. 

Bj’ Frederic Jay Cotton, M.D., and Gordon Mackay Morrison, M.D., Boston, Massachusetts. . 461 

A Bone Pl.\te Which Will Not Break or Bend. 

By George, IF. Hawley, M.D., Westport, Connecticut, and Ralph D. Padula, M.D., Norwalk, 

Connecticut 469 

Typhoid Spine. 

By H. .4. Swart, M.D., Charleston, West Virginia 473 

Bil.ateral Undescended Scapula with 0MO\'EnTEBRAL Bone. 

By Parker C. Carson, M.D., Springfield, Massachusetts 477 

Pregn.ancy Complicated by’ Osteopetrosis. Report of a Case. 

By Harley E. Artderson, M.D., Omaha, Nebraska 481 

Tr.axjmatic Malacia of Carpal Bones. A Case Report. 

By C. Tl’. Brainard, M.D., Battle Creek, Michigan 486 

Multiple Congenital Dislocation. 

By ill. Kamel Hussein, F.R.C.S., Cairo, Egypt 488 

Fracture or Evulsion of the Anterior Superior Spine of the Ilium. 

By E. N. Cleaves, M.D., Boston, Massachusetts 490 

Fracture of the First Rib Unassociated with Fractures of Other Ribs. A Case Report. 

By Tom Outland, M.D., and C. R. Hanlon, M.D., Sayre, Pennsylvania 492 

A Compact Pendulum Arthrometer. 

By John G. Hand, M.D., Philadelphia, Pennsylvania 494 

A Method for Skeletal Traction to the Digits. 

By G. Mosser Taylor, M.D., and Alonzo J. Neufeld, M.D., Los Angeles, California 496 

The Use of “Periosteal Sutures’’ in Open Fixation of Fractures of the Tibial Condy’le. 
Report of One Case. 

By Lester E. Garrison, M.D., and Monroe Garrison, M.D., Chicago, Illinois 498 

A Simple Technique for Inserting the Smith-Petehsen Nail. 

By Don King, M.D., San Francisco, California 501 

An Inexpensive, Durable Walking Cast. 

By John S. Stephens, M.D., Los Angeles, California 502 

A Modification of the Traction Treatment op Sacro-Iliac Strain. 

By Allan H. Warner, M.D., Woodside, Long Island, N. Y 503 

A Screw for Oblique Fractures. 

By R. M. Yergason, M.D., Hartford, Connecticut 504 

Spinal Htperextension Litter. 

Bj' Ralph D. Padula, M.D., Norwalk, Connecticut 507 

A Histopathological Study of the Synovial Membr.yne with Mucicarmine Staining. 
{Correction.) 

By James H. Cherry, M.D., and Ralph K. Ghormley, M.D., Rochester, Minnesota 516 

Patrik Haglund 511 

News Notes 513 

Current Literature 517 


13 


ENGEL-MAY TWO-PLANE DIRECTION and RANGE FINDER 



(End View) 

Illustration two-thirds size. 


For Fractures of the Neck 
of the Femur 

Insures correct placement of guiding 
wire. Instrument is simple to handle 
and accurate. Operation is shortened 
and non-shocking. 

See article in February 15th issue of 
“Surgery, Gynecology and Obstet- 
rics” page 495. 

Circular on request. 


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14 



OLD UNUNITED FRACTURES OP THE NECK OF THE FEMUR 


95 


111 the first type of case, in which the aim is to restore the structures 
to their former relative positions, it is not advisable to insist upon or even 
to advocate too exclusivelj’’ one method of reuniting the fragments. The 
essential principle is practically the same in all of the different procedures. 
In some, the surface is cleared of fibrous covering and thoroughly re- 
freshened; in all, the fragments must be replaced and held in firm apposi- 
tion. In the old cases, in which bone atrophy always exists, this firm 
contact is particularly imperative. Whether this retention is accom- 
plished by interposition of bone grafts, nails, or wires for fixation of the 
limb with or without artificial impaction, the maintenance of this contact 
is imperative in proportion to the diminished size of the head fragment and 
the amount of existing bone atrophy. In some of these cases the advisa- 
bility of extraneous material, with the local trauma incident to its inser- 
tion, is decidedly debatable. It is the author’s belief that sound surger}'^ 
demands the largest possible contact of cancellous bone on each fragment 
and the least amount of e.xtraneous material placed in these parts. The 
transplantation of the head fragment to the freshened upper and inner 
surface of the trochanter, with so large a surface of bone contact, in a 
position which does not tend to displace, frequently provides the best 
physiological conditions for quick return of vitality to the head fragment. 

In the other type of case, in which there is not sufficient normal 
structure remaining to permit joint function, the choice of procedure is 
somewhat more difficult. With the marked atrophy of the head, the thin- 
ning or disappearance of the cartilage line, and the arthritic changes 
around the joint, either about the femur or the acetabulum, or both as is 
usually the case, the potential for good function (weight-bearing and mo- 
tion without pain) is not offered. It is necessary to estimate how much 
function, based on the consideration of both local and general conditions, 
as well as on the social status, it is pos.sible to expect, and then to select 
that operative procedure which seems best fitted to fulfill these indications. 
We must choose between the use of the remaining articular structures 
placed in contact with the acetabulum, with the object of obtaining a 
pseudarthrosis — whether by the method of Whitman, by putting the 
lesser trochanter into the cavity of the acetabulum, or by some of the more 
recent modifications of reconstruction operations — or an immediate 
ankylosis, sacrificing the convenience of motion to the greater strength 
and to the more practical use of painless weight-bearing. 

The various operative procedures with their rather refined techniques 
and the manj’- mechanical devices which may be employed have been so 
elaborated and often perfected, and the different conservative measures 
with their results have been so freelj"^ given to the medical public, that we 
have now quite a sufficient equipment to meet whatever conditions are 
presented. At present there is need of special studj’’ and observation, 
particularlj’^ by the collection of 'end results, to aid in the application 
of these methods which we already have to the various types of cases, and 
to act as a guide in the choice of the method of treatment. The re.-^ult 


VOI.. XX. XO. 1, JANUARY 193S 



94 


E. G. BRACKETT 


selected, the following features are to be taken into account: the character 
of the break; the amount of absorption of the neck; the size of the head and 
the amount of atrophy; the condition of the acetabulum and, in fact, of all 
the remaining structural elements of the joint which may be used in 
restoring function by whatever method the operator may decide to em- 
ploy. Of equal importance with the local factors are the general factors,— 
namely, the age; the general condition; the amount and kind of activity 
engaged in by the patient; and the demands which his social status will 
put on the restored joint. 

The various accepted methods of operation, with their modifications, 
can be easily put into two groups, according to the principles upon which 
they are based and the goal which they attempt to reach : 

1. Those which, in the presence of intact articular structures, aim 
to preserve the parts and to restore as far as possible the normal architec- 
ture of the joint. 

2. Those which, in the absence of normal joiiit structures, are de- 
structive in principle and aim to use non-articular structures to perform a 
portion of the role of the normal joint structures. 

The former attempts to restore to the joint a large percentage of 
normal function; the latter makes no such attempt, but, with the use of 
other non-articular structures, endeavors to regain as much of the normal 
function with weight-bearing as existing anatomical conditions can with 
reason promise. The employment of the first type presupposes the 
presence of articular structures sufficiently normal to resume joint function 
when the architecture has been .sufficiently restored ; the other accepts the 
damaged parts as a fact and endeavors to use them to the best advantage, 
recognizing that an imperfect joint must be accepted as a final result. 
Each case calls for an estimate of its potential capacity for function, based 
on the condition of the joint structures which remain. 

In this estimate, it is necessary to formulate the essentials of a normal 
joint, — namely, (1) normal area and line of the joint cartilage; (2) freedom 
from arthritic changes; (3) preservation of a reasonable degree of bone 
density of the head fragment. It is a fact that some degree of change in 
the structure of an uninjured joint is compatible with satisfactory use, 
but it must be recognized that, after so severe an injury, these changes 
gradually become more pronounced, with a resultant increasing incapacity. 
Therefore, when these articular changes exist, even if they are not pro- 
nounced, the joint is not likely to stand the test of time and of the stress of 
an active life. These facts must be reckoned with in^planning for the late 
end result, and these local conditions must influence the choice of proce- 
dure. Along with this, the social status of the patient makes equally 
strong demands for recognition and often must be the important deciding 
factor. The decision, therefore, must be made as to whether we shall 
attempt to restore, as far as possible, the normal architecture and function 
of the joint, or whether we shall compromise and be content with a less 
perfect end result. 


THE JOURNAL OF BONE AND JOINT .SURGERV 



COMMENTS ON INTERNAL FIXATION IN FRESH 
FRACTURES OF THE NECK OF THE FEMUR * 

BY W. W. PLUMMER, M.D., BUFFALO, NEW YORK ' 

The whole problem of the treatment of fresh fractures of the neck 
of the femur has been so thoroughly discussed in the literature that it is 
unnecessary to undertake a preliminary presentation of the history of 
the development of this procedure. It is sufficient to state that, since 
Smith-Petersen’s work in 1931, there has been a rapidly growing convic- 
tion on the part of many surgeons that internal fixation of these fractures 
is the ideal method of treatment for this group of serious and disabling 
injuries. 

In this paper the reader will recognize the influence of the work of 
many men who have already demonstrated the fundamentals in this par- 
ticular field. AVithout later specific references to writers or to details of 
method, the author wishes to pay tribute to the courage and ingenuity of 
Smith-Petersen, Johansson, Gaenslen, Moore, Wescott, AVhite, and others 
who have contributed to the development of this excellent operation. 
Our own personal experience with internal fixation of hip fractures, while 
brief in time, includes enough cases to warrant the expression of an opinion 
as to the general desirability and justification of this method of treatment. 

ANALYSIS OF CASES 

Since September 1935 and up to May 1, 1937, there have been re- 
ferred to our Service in the Buffalo General Hospital a total of thirty-seven 
consecutive cases of fresh fracture of the femoral neck. Of these patients, 
two died almost as soon as they were admitted to the Hospital. All of the 
remaining thirty-five patients were operated upon and some form of in- 
ternal fixation was employed. Thirty-three cases would properly be 
classed as intracapsular fractures, while two were fractures at the base 
near the trochanter. The ages of the patients ranged from forty-six to 
ninety-two, and at one time the average age was seventy-eight. Lately 
the average has fallen to about seventy-five. Nine of the thirty-five 
patients in this series have died, — ^two within the ten-day postoperative 
period. The other seven survived for periods varying from one month 
to eighteen months, and died of cancer, incorrigible diabetes, and other 
causes due to their senescent state. 

RESULTS 

The immediate postoperative results in this series of cases would 
alone, in the author’s opinion, be sufficient justification for the internal- 
fixation operation. The patient is comfortably and easily cared for in 

* Read at the Annual Meeting of the American Orthopaedic Association, Lincoln 
Nebraska, June 2, 1937. ’ 


VOL. XX. XO. l, JAXUARY 1!13S 


97 



96 


E. G. BRACKETT 


after a few months, or even after a few years, may not furnish accurate 
evidence for the estimation of the value of the procedure. Even the 
mechanical irritation accompanying the use of an imperfect joint may be 
sufficient to change the first indication of success into the final fact of 
failure. These joints, traumatized by the original injury and later by 
operation, show marked anatomical and pathological defects and they 
often continue to exhibit progressive changes in their character, so that 
true end results cannot be estimated until after a much longer period 
than that of the usual fracture case. 

The definite demand at present is not the study of the end results of 
a special method of treatment or of a particular technique. These various 
procedures have been given sufficient prominence to enable any surgeon 
of ability and experience to use any one witli precision. What is needed 
is a more thorough study of the various conditions which these different 
joints present, with the means of estimating the potential capacity of each 
to respond to the demands Avhich the activities and the social status of the 
patient will make on it in the years which follow, in order to determine 
which operation promises to give the type of joint best suited to the in- 
dividual’s needs. We should have more knowledge of end results ob- 
tained by the various procedures which have been selected with reference 
to the potential function which remains to a joint after it has passed 
through the trauma of the injury and the superimposed trauma of any 
operative procedures. Such data would aid us to choose more wisely the 
course to pursue. 




THE JOURNAL OF BONE AND JOINT SURGERY 



FRACTURES OF THE NECK OF THE FEMUR 


99 


that we classify our end results in terms of walking function without 
relapse into varus — external-rotation deformity — rather than by roent- 
genographic interpretations of the extent of the bony trabeculation 
bridging the fracture line. What will ultimately become of the non- 
vitalized head, if such it is in cases without bony union, still remains to be 
determined after a longer and more extensive experience. 

TYPE OF OPERATION 

From the start of our series we have elected to reduce these fractures 
and to fix the fragments without opening the hip joint. All of the patients 
have been operated upon by way of the lateral thigh incision, exposing the 
trochanter and adjacent shaft. This plan was followed for the same reasons 
as have been given by other men advocating this type of operation. 

The operation involves additional apparatus and equipment in that it 
requires efficient x-ray facilities in the operating room and some special 
instruments of precision. However, it makes possible the benefits of 
internal fixation for many frail and aged patients who could not possibly 
be expected to survive both a hip fracture and an arthrotomy. Also the 
author believes that in an arthrotomy the section of many of the support- 
ing tissues of the hip joint, including the capsule, has often led the surgeon 
to the faulty assumption that open reduction is necessary. 

METHOD OF REDUCTION 

In general, we have followed the Whitman-Leadbetter procedure of 
reduction, in which the injured leg is fixed in full internal rotation, with 
such flexion and abduction as seems wise. Apparently in practically all 
of our cases the posterior capsule was sufficiently intact to act as a splint 
for the reduced fracture and to hold the fragments in firm contact when the 
leg was fully rotated inward. In two cases, internal rotation rolled the 
neck fragment onto the front of the head, and lateral traction was neces- 
sary to adjust the fragments. When anteroposterior and lateral roent- 
genograms showed the reduction to be satisfactory, the position of the leg 
was not shifted until the operation was completed. This was accom- 
plished by a special table which, by means of mechanical devices, was 
readily adjustable to any desired leg position and maintained a continu- 
ously fixed relationship between the femur and the x-ray projection ap- 
paratus. This complete and continuous mechanical holding of the injured 
leg, plus an x-ray technique which produces uniform roentgenograms of 
the hip joint from accurately standardized distances and angles, consti- 
tutes the most important part of the operation. In fact, the writer feels 
that the recent remarkable advances in roentgenography have made it 
possible to transform the so-called “blind hip-nailing operation” into a 
precision procedure. 


FIXATION INSTRUMENTS 

In our series we have used IQrschner vdres, Austin Moore pins, and 


VOL. XX. XO. I. JAXUAnV 193S 



98 


W. W. PLUMMER 


bed, he has no pain, and he is completely relieved of the apprehensions of a 
long and exhausting bedridden period in plaster or traction. 

It would, of course, be ridiculous to discuss end results in this series, 
but a rough analysis of functional results is interesting. Twenty-six of 
the patients are living. Four have been operated upon too recently to be 
counted at this time; the remaining twenty-two are comfortably ambula- 
tory, their functional ability apparently depending on their age and general 
condition rather than on what might be termed their actual hip function, 
which seems to be good. 

With the exception of one hip with a fracture near the trochanter, 
none of these hips up to this time have shown any tendency to relapse into 
the external rotation — varus deformity — present in all cases of fracture of 
the hip. In this one case, in the fourth week, the roentgenogram showed 
a collapse of the posterior fracture area with an external rotation — varus 
relapse. However, the patient now has a painless stable hip with better 
function than the roentgenogram would lead one to expect. The 
follow-up roentgenographic examinations in all these cases demonstrated 
a varying degree of neck shortening, but no evidence of change from the 
stable weight-bearing relationship of the fragments attained at the time of 
reduction. The writer has been surprised at the absence, up to the pres- 
ent time at least, of any signs of arthritic changes in these hips. All of 
the patients have shown a remarkable recovery of balance and muscle 
tone; in fact, none of them has suffered any of the usual muscle atrophy 
and loss of knee function associated with the use of plaster or traction 
fixation. 


CRITERIA FOR END RESULTS 

In evaluating end results, the writer believes that too much emphasis 
has been placed on the feature of apparent bony union. It is a well- 
known fact that, no matter what the method of treatment, a certain 
number of cases of hip fracture in all the age brackets have eventually 
progressed to a demonstrable solid bony trabeculation across the fracture 
area. However, it seems to the author that one could reasonably express a 
doubt as to the roentgenographic interpretations usually presented as a 
basis for the reports of a high percentage of cases of bony union resulting 
from this or that procedure. In the majority of the younger patients, 
with good reduction and internal fixation, bony union can be expected. 
This is confirmed roentgenographically after a sufficient length of time, 
by the areas of repair invasion of the head by new bone trabeculae from 
the neck in the manner suggested by Phemister. This favorable result 
will be obtained only if the fixation method has been effective in retaining 
the proper weight-bearing relationship of the fragments. 

In the older patients, we probably must be satisfied with a satisfac- 
tory weight-bearing function, and perhaps assume that the fixation nail 
will be the chief factor in maintaining a useful leg for these patients during 
the rest of their lives. In other words, the writer would like to propose 


THE JOURNAL OF BONE AND JOINT SURGERY 




100 


W. W. PLUMMER 


the Smith-Petersen trefoil nail. In the first four cases the fragments were 
speared with the wires. This is not a satisfactory method. The wires are 
inadequate mechanically, dangerously prone to wander into the pelvis, 
and, in the writer’s opinion, should be abandoned. In the next eighteen 
cases the Moore multiple pins were used. This method has in our hands 
produced consistently good results. However, here again the method 
fails to satisfy completely the mechanical requirements. Only one of the 
three pins can be located in the cortex, neck, and head, so as to resist 
effectively the sheering strain of muscle pull and weight-bearing. While 
the combined surface areas of the three pins is approximately only 20 



Fig. 1 


Table device which makes possible the determination of the exact point of en- 
trance of the nail, of its length, and of the angle of incidence to the shaft. 


FRACTURES OF THE KECK OF THE FEMUR 


101 


per cent, less than that of the usual trefoil nail, the area is so divided as 
to be much less efficient in all three of the mechanical factors, — namel3’’, 
resistance to sheering strain, rotary movement of one fragment on the 
other, and, of less importance, anjr po.ssible “draft” effect which the 
fastening might ha^'e. In all of the remaining cases of this series the 
trefoil nail has been emploj’-ed. 

It seems to the author that the Smith-Petersen nail as modified by 
Warren White meets in everj’- way the requirements for this type of fixa- 
tion instrument. Beautifull}’- machined from completely corrosion- 
resistant chrome-nickel steel, its thin, sharp blades disturb a minimum 
amount of bone, while its flat surfaces and slightlj’- more bulky head tend 
to anchor the nail fimly in the compact cancellous bone of the femoral 
head, as well as in the denser cortex of the shaft. The writer can see no 
advantage in the use of threaded screws or bolts, and certainly no metal 
that undergoes chemical corrosion or electrolysis should be inserted into 
these bones. Chrome-nickel steel of accepted formula is both corrosion- 
resistant and non-magnetic. Two of these nails were immersed in a solu- 
tion corresponding to the physiological body fluids at body temperature, 
one under aerobic and 
the other under an- 
aerobic conditions, for 
three months. After 
removal, neither nail 
showed even a sug- 
gestion of tarnish or 
of oxadation. 

OPERATn'E TECHNIQUE 

Following closelj’ 
the procedures of 
Smith-Petersen, 

Johansson, and Wes- 
cott, we have, at the 
time of publication of 
this article, operated 
on forty-three fresh 
fractures of the neck 
of the femur in forty- 
two patients. In no 
instance has the hip 
joint been opened, in- 
ternal fixation after 
reduction having been 
attained ^•ia the usual 

lateral thigh incision. Pjc 3 

The determination of Graph for calculating the actual neck length. 

VOL. XX. XO. I. JAXfAHY 193“! 




102 


W. W. PLUMMER 



Fig. 4 

Modification of Wescott’s protractor bj’- 
which, on the postreduction film, the angle 
for the proper nail location is read and the 
total length of cortex, neck, and head is 
determined. 


the exact point of entrance of the 
nail, of its length, and of the angle 
of incidence to the shaft is made 
possible by the table device shown 
in Figure 1. With the patient al- 
ready in position on the flat Bucky 
diaphragm, the fracture is re- 
duced and the leg holder is ad- 
justed to the leg in any position 
which seems proper. The usual 
leg position is the one shown in 
the illustration, — namely, mod- 
erate flexion and abduction and 
full internal rotation. In this 
way the injured leg remains con- 
stantly and rigidly fixed in rela- 
tion to the top and edge 



of the Bucky diaphragm, 
so that anteroposterior 
and lateral roentgeno- 
grams of the neck of the 
femur will be exactly 
duplicated throughout 
the entire operation. In 
making the anteropos- 
terior roentgenograms, 
the x-ray tube is always 
centered over the hip at 
exactly the same dis- 


Fig. 5 


tance from the top of 


Divider used to measure on tie postreduction film 
the distance down the shaft from the ridge. 


the Bucky diaphragm. 
The lateral roent- 


genogram, shown in Figure 2, is made by aiming the tube at the femoral 
neck along an imaginary line called the pelvic line, from the lower edge 
of the s^miphysis pubis to the superior iliac spine, with the central beam of 
the tube inclined exactly 35 degrees below the horizontal. The cassette 
in its sterile cover rests on the top of the Bucky diaphragm with the edge 
pressed into the patient’s flank and its surface at right angles to the pelvic 
line and inclined out against a light metal support, exactly 35 degrees from 
the vertical. At this time also a measurement is taken from the top of 
the table to the center of the mass of the femoral shaft as outlined by the 
thumb and forefinger (Fig. 1). By means of this measurement, the exact 
distance of the hip from the x-ray film can be computed for any given 
patient . It is called ‘ ‘ hip height,” it varies widely in different patients, and 
it is important if we are to compute accurately from the roentgenographic 
findings the actual distance from cortex to head in any given patient. 


THE JOURXAL OF BOKE AXD JOIN'T SURGERY 




FRACTURES OF THE NECK OF THE FEMUR 


103 


Assuming that the position is satisfactory, the postreduction films are 
nowread}’’ foruse. B}’’ using a modification of Wescott’s protractor with its 
base on the edge of the film (Fig. 4), certain data are obtainable. The angle 



Fig. 6 

Small drill and dividers used to 
spot the entrance of the nail. 


from the ridge is measured with a 


for the proper nail location is read. 
The total length of cortex, neck, and 
head along this line is determined and 
noted. The distance down the shaft 



Fig. 7 


A long, fairly stiff guide wire is drilled 
into the shaft, neck, and head. Note 
the adjustable stop located on the wire 
at the predetermined nail length from 
its entering tip. 


divider (Fig. 5). While these angles and distances are being noted, similar 


sterile instruments are being set and adjusted by the operating-room nurse. 


To save time in calculating the actual neck length in the patient. 


which is a matter of arithmetical pro- 
portion, we have a prepared graph 
(Fig. 3) based on a constant height 
from tube center to film used in all 
cases. The left-hand column repre- 
sents the height of the hip from the 
film. The right-hand column shows 
the length of the neck as measured on 
the roentgenogram. For example, if a 
straight edge is placed on S inches in 
the left-hand column and on the roent- 
genographic measurement, 6.S inches 
in the right-hand column, it will cross 
the center line just above 4, which will 
be the exact length in inches from shaft 
to head, and a nail, three and three- 
quarters inches in length, is indicated. 

With the lateral aspect of the shaft 



Fig. 8 

Nai! lying full length in the denser 
portions of the bone. 


VOL. XX. NO. 1. JAXITARY 193S 



104 


W. W. PLUMMER 




FRACTURES OF THE NECK OF THE FEMUR 


105 



Fig. 11 

Lateral roentgenogram to check the position of the nail. 


exposed, the point of entrance of the nail is spotted with a small drill and 
the dividers as shown in Figure 6. With a protractor constructed to 
transfer the angle read from the roentgenogram to the operating table in a 


generally horizontal 
plane, a long, fairly 
stiff guide wire is 
drilled into the shaft, 
neck, and head. An 
adjustable stop is lo- 
cated on the wire at 
the predetermined 
nail length from its 
entering tip. (See 
Figure?.) We try to 
keep the guide wire in 
contact with the in- 
ferior surface of the 
medullary canal of 
the neck in order to 
later place the nail so 
that its full length lies 
in the denser portions 
of the bone as shown 
in the specimen illus- 
trated in Figure 8. 
If the Warren White 
instruments are used, 
the nail is easily and 
accurately driven 



Fig. 12 


Ninoty-ilcgrce projection taken after the wouiul had 
been elosed and dre.ssed. 


VOL. XX. XO. 1. JAXr.\nY ID3S 



106 


W. W. PLUMMER 



Fig. 13-A Fig. 13-B 

Roentgenograms of right and left hips taken in August 1937, showing in each case 
some shortening of the neck, but the weight-bearing relation of the head is good. 


parallel to the guide wire and at such inclination to the horizontal surface 
of the table as has been determined by the first lateral roentgenogram 
taken. 

Figures 9 and 10 show the guide wire in place and the nail driven. 
Figure 11 is a lateral roentgenogram to check the position of the nail. 
Finally, after the wound has been closed and dressed, the thigh is flexed at 
a right angle and the 90-degree projection shown in Figure 12 is made if 
desired. 

While the procedure described may sound complicated, it is really 
very simple. No novelty is claimed for any part of it, with the possible 
exception of the table and x-ray combination, and here our only point is 
that, with fixed and rigid relations of leg to roentgenographic-projection 
distances and angles, it becomes possible to insert and to drive the light 
sized nail at the proper location with complete confidence and assurance 
that the nail will not go astray. The whole procedure takes from fifty to 
seventy minutes from the time the patient is placed on the table. This 
includes reduction, the taking of the three sets of two films each to check 
reduction, the insertion of the guide wire and nail, and of course the actual 
operating time which is really quite brief. 

The roentgenograms shown in Figures 13-A and 13-B are interesting 
and were made late in August 1937. The patient, aged seventy-eight, was 
operated upon early in March 1937, and a fracture of the left hip was re- 

THE JOURNAL OF BONE AND JOINT SURGERY 




FRACTURES OF THE NECK OF THE FEMUR 


107 


duced and the fragments were nailed. In July she was walking comfort- 
ably with a good functional left hip, when she fell over a rug fracturing the 
right femoral neck. An operation was performed on this hip and the 
fragments were nailed. Both femoral necks show some shortening, but 
the weight-bearing relation of the head remains good. The patient is 
apparently once more on her waj'^ to obtaining useful and comfortable 
function of both hips. 


CONCLUSIONS 

1. Internal fixation of fresh fractures of the femoral neck has been 
demonstrated by the work of many surgeons to be a justifiable and reliable 
method of treatment for this important and serious injury. 

2. Internal fixation of these fractures can be accurately and suc- 
cessfully accomplished without the added hazards of a hip-j oint arthrotomy. 

3. This procedure should not be classified as a simple and casual 
operation to be done under any and all conditions. However, judged on 
the merits of reported results from many clinics, this plan of treating hip 
fractures is worth all it costs in the way of expensive and special equip- 
ment and deserves the thoughtful consideration of all surgeons charged 
with the care of these cases. 


REFERENCES 

Gaenslen, F. J.: Subcutaneous Spike Fixation of Fresh Fractures of the Neck of the 
Femur. J. Bone and Joint Surg., XVII, 739, July 1935. 

Fracture of the Neck of the Femur. Sir Robert Jones Lecture in 
Orthopedic Surgery. J. Am. Med. Assn., CVII, 105, 1936. 

Johansson, Sven: On the Operative Treatment of Medial Fractures of the Neck of the 
Femur. Acta Orthop. Scandinavica, III, 362, 1932. 

A Case of Pseudarthrosis of the Neck of the Femur Treated by a 
Method of Extra-Articular Osteosynthesis. Acta Orthop. Scandinavica, IV, 214, 
1933. 

Moore, A. T.: Fracture of the Hip Joint (Intracapsular) ; a New Method of Skeletal 
Fixation. J. South Carolina Med. Assn., XXX, 199, 1934. 

Fracture of the Hip Joint — A New Method of Treatment. Internat. 
Surg. Digest, XIX, 323, 1935. 

Fracture of the Hip Joint. Treatment by Extra-Articular Fixation with 
Adjustable Nails. Surg. Gynec. Obstet., LXIV, 420, 1937. 

Phemistbr, D. B.: Fractures of Neck of Femur, Dislocations of Hip, and Obscure Vas- 
cular Disturbances Producing Aseptic Necrosis of Head of Femur. Surg. Gynec. 
Obstet., LIX, 415, 1934. 

Smith-Petersen, M. N.; Cave, E. F. ; and VanGohder, G. W. : Intracapsular Fractures 
of the Neck of the Femur. Treatment bv Internal Fixation. Arch. Surg., XXIII, 
715, 1931. 

Wescott, H. H.: a Metliod for the Internal Fixation of Transcervical Fractures of the 
Femur. J. Bone and Joint Surg., XVI, 372, Apr. 1934. 

White, J. W.: An Instrument Facilitating TTse of the Flanged Nail in Treatment of 
Fractures of the Hip. J. Bone and Joint Surg., XVII, 1065, Oct. 1935. 


VOL. XX. NO. I. JANUARY lOSS 



CLOSED REDUCTION OF FRACTURES OF THE NECK OF THE 

FEMUR* 

BY GUY W. LEADBETTER, M.D., WASHINGTON, D. C. 

In the treatment of intracapsnlar fractures of the neck of the femur, 
the efficacy of any single procedure depends on the skill of the individual 
surgeon, his judgment, his experience with the type of fracture at hand, 
and the general condition of the patient with particular reference to his 
recuperative powers and to no small extent to his mental cooperation. 
The cardiovascular-renal system should be examined carefully for any 
organic disease or decompensation. Dehydration, when present in the 
elderly patient, should always be recognized and treated before any at- 
tempt to correct the injury is made. Intestinal stasis is an important 
element to be considered, especially in the patient of advanced years. 

At the present time two general types of procedure are widely used 
by qualified fracture surgeons. One school of thought advocates closed 
reduction and plaster fixation; the other chooses closed reduction with 
some form of internal fixation, the Smith-Petersen nail being used by the 
majority, although the three-pin internal fixation has been reported to 
have yielded excellent results. The technique, however, of both of these 
operations is essentially the same. 

The end results of the treatment in the past are shown in Table I. 

The author wishes to report a series of eighty-one cases treated for 
fracture of the neck of the femur. Fifty-nine of these were followed 
accurately. The ages of these fifty-nine patients ranged from forty to 
ninety-two years, and the period of observation extended from one to 
nine years. All of the patients were treated by closed reduction and 
skin-coaptation plaster fixation. Good union resulted in 71.18 per cent.; 
good function but no bony union in 6.79 per cent. ; failure in 13.57 per cent. ; 
and death in 8.46 per cent. Thus 22.03 per cent, of the cases resulted in 
failure. The average time in plaster was ten weeks. The average time 
of recumbency was twelve weeks. Full weight-bearing was not allowed 
for six months. 

These results are apparently commensurate with those reported in 
other recent series and seem to represent about all that may be expected 
from this particular procedure, although ambulatory treatment such as 
that suggested by Kleinberg may offer a higher percentage of good end 
results. There is considerable ingenuity in this procedure and we should 
not be too hasty in condemning such technique. 

Meticulous attention to the pi'oper and anatomically accurate reduc- 
tion of the fragments is certainly the first step in any procedure. To be 
satisfied with even an appro.ximate reduction is not sufficient, statements 

*Read at the Annual Meeting of the American Orthopaedic Association, Lincoln, 
Nebraska, June 2, 1937. 

](]§ THE JOURNAL. OF BONE AND JOINT SURGERV 



End Results of Closed Reduction of Fkactures op the Neck of the Femur 


FRACTURES OF THE XECK OF THE FEMUR 


109 


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VOL. XX, XO. I. JAXUAHV 193S 


Counlin)' three iraticnts who died. 
Counting two patients rvho died. 



no 


G. W. LEADBETTER 


to the contrary notwithstanding, no matter what the method of fixation 
may be. It has been conclusively shown that these fractures can be 
reduced by careful manipulation. 

For the sake of clarity, it seems wise to reiterate the steps in reduction 
and fixation described in the paper read by the author at the meeting of 
the American Orthopaedic Association in Toronto in 1932. The injured 
leg is flexed at the hip at 90 degrees. Manual traction is applied in the 
axis of the flexed thigh, together with slight adduction of the femoral 
shaft. In this position the thigh is internally rotated, and the leg is 
slowly circumducted into abduction, the internally rotated position being 
maintained. As the leg is brought down to the table level, the heel-palm 
test should be applied to confirm position. The amount of measured 
abduction is determined by inspection of the roentgenograms taken 
previous to the manipulation, and the angle of the uninjured side is com- 
pared with that of the fractured side. The difference in degrees between 
the two angles is roughly the amount of abduction required. It can be 
still more accurately determined and verified by applying the heel-palm 
test which allows only a few degrees’ variation in abduction or adduction 
before change in the position of the leg takes place, — for example, if the 
leg is carried too far toward the adduction side, it will slowly evert itself 
in the palm of the hand and give evidence of disengagement of the frag- 
ments. If abduction is forced beyond the normal limits necessary to 
maintain coaptation of the fragments, then greatly increased tension of 
the adductor muscles will be felt and there will be a tendency for the knee 
to flex slightly. This has been found to be a very satisfactory method of 
determining the amount of abduction in the reduced fracture. The leg is 
then held by an assistant without traction, and the plaster is applied as 
follows. A one-layer thickness of glazed cotton is placed about the torso 
from the nipple line over the affected hip to a point about half-way be- 
tween the hip and the knee. Then a long strip of felt, one-half an inch 
thick, is placed about the pelvis, extending from just above the iliac crests 
to the trochanters, and completely encircling the pelvis. This is all the 
padding necessary and allows very tight application of the plaster. The 
body portion is first applied as tightly as possible, snug coaptation being 
the aim. Firm pressure over the injured hip is necessary. Below the 
hip no padding is applied. Two plaster slabs, molded carefully to the 
contour of the leg, are bandaged closely to the skin, one posteriorly and 
one anteriorly. Padding is placed beneath the heel, and the plaster is 
molded well and coapted snugly. Circular plaster is applied around the 
two molded leg splints. Care is taken to carry the cast high under the 
pubis and the ischium with sufficient felt padding which is cut very closely 
in the trimming of the cast. The U is then cut from the body segment 
of the cast anteriorly, leaving the sides high in order to prevent the 
patient from swinging to the opposite side, thereby changing the relative 
position of body and leg. Extreme abduction is rarely necessary. It is 
quite clear that the valgus position is best. Only in rare cases does full 


THE JOURNAL OF BONE AND JOINT SURGERY 



FRACTURES OF THE NECK OF THE FEMUR 


111 


abduction allow such valgus position. It has been the author’s experi- 
ence that by far the majority of cases demand very little abduction. 

Several men have indicated that they change the plaster after three 
weeks. This is to be commended, especially in handling stout individuals. 
We all experience the problem of the loose cast in such patients Fixation 
is less secure, although the skin-coapted plaster diminishes the chance of 
slipping. The necessity for change may be determined by frequent in- 
spection of the cast. Roentgenograms taken immediately after applica- 
tion of the cast and at intervals of two weeks show change of position of 
the fragments If malposition is noted without absorption of the neck, 
reduction should again be done and the case treated as before. 

During the active convalescent period it has been our custom to put 
the patient in the erect position as soon as possible, permitting him to 
walk vdthout a caliper brace but with crutches. While no weight-bearing 
is allowed, he is painstakingly taught to walk with regular rhythm of gait, 
touching the foot of the injured leg to the floor but not applying any 
force. In this way an early regulation of gait is established. There is a 
fairly rapid improvement in the tone of the muscles of the hip and the 
leg, and it is not so difficult, when the time comes, to wean the individual 
from crutches. Two canes are first substituted and these are rapidly 
followed by one. The discarding of the last cane is left largely to the 
patient’s discretion. 

As shown by the reported results in the last eight years, the efficiency 
of treating these fractures has increased. We should bear in mind that 
probably no single method is adaptable to all cases and to all localities. 
A recent q.uestionnaire which the author sent to orthopaedic surgeons, 
to general surgeons, and to general practitioners in all sections of the 
country revealed some interesting figures. They grouped themselves 
very sharply into two units. The agreement of estimated figures in 
these units was striking. 

In the cities of 20,000 population and over, it was found that an aver- 
age of 71.18 per cent, of the cases were treated by the orthopaedic sur- 
geons, 23.5 per cent, by the general surgeons, and 5.5 per cent, by the 
general practitioners. The procedure employed was chiefly plaster ap- 
plication with the abduction treatment and internal fixation. Practically 
no cases of actual open reduction were reported. 

In cities and towns of 20,000 population and under in the rural di.s- 
tricts, an average of 39.9 per cent, of the fractures of the neck of the femur 
were treated by the orthopaedic surgeons, 46.1 per cent, by the general 
surgeons, and 14.1 per cent, by the general practitioners. Here the treat- 
ment varied widely from sand-bags to suspension traction, the Roger 
Anderson splint, plaster, and only occasionally internal fi.xation. 

These figures present an argument in favor of teaching two methods, — 
namely, closed reduction with plaster cast and closed reduction with 
internal fixation. 

We cannot know what dire results ma 3 '- present themselves if those 


VOI,. XX. XO. 1. JANUARY 103S 



TABLE OF CONTENTS 


The First Stages of Coxa Plana. 

By Henning Waldenstrom, 71/.D., Stockholm, Sweden 559 

^ The Results of Postural Reduction of Fractures of the Sfine. 

By R. Watson- Jones, F.R.C.S., Liverpool, Enghind 5G7 

The Healing of Fractures of Atrophic Bones. 

By Joseph Gois7nan, M.D., and Edouard L. Compere, il/.Z)., Chicago, Illinois 587 

An Arthroplastic Procedure for Congenital Dislocation in Children. 

By Paul C. Colonna, M.D., Oklahoma City, Oklahoma 604 

. Recurrent Deformities in Stabilized Paralytic Feet. A Report of 1100 Consecutive 
Stabilizations in Poliomyelitis. 

By C. H. Crego,Jr., M.D., and H. R. McCarroll, ilLD., St. Louis, Missouri 609 

Non-Union and Bone Grafts. 

By Lt. Colonel Norman T. Kirk, M.D., San Francisco, California 621 

Transplantation of the Fibula in the Same Leg. 

By TF. B. Carrell, M.D., Dallas, Texas 627 

Bone Grafts in Ununited Fractures. 

By Melvin S. Henderson, M.D., Rochester, Minnesota 635 

The Use of Multiple Small Bone Transplants in the Treatment of Pseudarthrosis of the 
Tibia of Congenital Origin or Following Osteotomy for the Correction of Con- 
genital Deformity. 

By Halford Hallock, M.D., New York, N. Y 648 

Myositis Ossificans. 

By Charles F. Geschickter, M.D., and /. H. Maseritz, M.D., Baltimore, Maryland 661 

The Diagnosis and Treatment of Sacro-Iliac Conditions by the Injection of Procaine 
(Novocain). 

By Keene 0. Halde?nan, M.D., and Ralph Soto-Hall, M.D., San Francisco, California 675 

The Sciatic Nerve and the Piriformis Muscle: Their Interrelation a Possible Cause of 

COCCYGODYNIA. 

By Ldndsay E. Beaton, M.D., and Barry J. Anson, M.D., Chicago, Illinois 686 

Cord Injury During Reduction of Thoracic and Lumbar Vertebral-Body Fracture and 
Dislocation. 

By B^’UliamA. Rogers, AI.D., Boston, Massachusetts 689 

Treatment of Injuries of the Cervical Spine. 

By TF. Gayle Crutchfield, M.D., Richmond, Virginia 696 

An Operation for the Correction of Hallux Varus. 

By S. L. Haas, 31. D., San Francisco, California 705 

Ossification in the Ligaments of the Elbow Joint. 

By St. J. D. Buxton, F.R.C.S., London, England 709 

An Operation for the Correction of Hammer-Toe and Claw-Toe. 

By Charles S. Young, 31. D., Los Angeles, California 715 


{Continued on page 13 following Current Literature) 



FRACTURES OF THE NECK OP THE FEMUR 


113 


Mooue, a. T.: Fracture of the Hip Joint — A New Method of Treatment. Internat. 
Surg. Digest, XIX, 323, 1935. 

Fracture of the Hip Joint. Treatment by Extra-Articular Fixation with 
Adjustable Nails. Surg. G 3 mec. Obstet., LXIV, 420, 1937. 

Reggio, A. W. : Fractures of the Femoral Neck. An End-Result Study of N on-Operative 
Treatment. J. Bone and Joint Surg., XII, 819, Oct. 1930. 

Smith-Peteksen, M. N.; Cato, E. F.; and VanGorder, G. W.; Intracapsular Fractures 
of the Neck of the Femur. Treatment by Internal Fixation. Arch. Surg., XXIII, 
715, 1931. 

Stern, W. G.; Reich, R. R.; Heyman, C. H.; and Papurt, L. E. : The Treatment of 
Intracapsular Fracture of the Hip Joint by the Method of Extension, Abduction, 
and Internal Rotation (Whitman’s Method), with Especial Reference to the Group 
Age, SLxtj^ and Beyond. Surg. Gjmec. Obstet., LIII, 250, 1931. 

Walker: Quoted bj"- Dickson. 


VOL. XX. XO. 1. JANUARY 193S 



112 


G. W. LEADBETTER 


unskilled in the technique of internal fixation attempt such treatment, 
and, until we are able to educate the profession and the laity in general 
to the fact that internal fixation is a technical procedure, it is the author’s 
feeling that we should continue to teach the old method as well as the new. 

These two procedures are truly a fine armamentarium and, as in 
other fractures, the writer feels that we should apply the rule of conserva- 
tism whenever reasonably possible and utilize internal fixation when in 
our judgment it is necessary. In the last year and one-half we have ap- 
plied this rule with what appears at the present time to be very satis- 
factory results, although the cases have not been followed long enough to 
state so definitely. We have nailed approximately 75 per cent, of the 
fresh fractures and in the remainder have applied the plaster-fixation 
method. 

In selecting the cases, the patient’s age, his general physical condi- 
tion, his muscular condition, and, to no small extent, his choice (some 
patients object to nailing) must be considered. 

It is not by one single stereotyped form of treatment that the problem 
of the fractured hip will be solved. Both plaster fixation and internal 
fixation should be taught. Open reduction is not necessary, but, in the 
final analysis, it cannot be denied that internal fixation is more adequate 
than plaster, and that early mobilization of the individual is most im- 
portant in preventing chronic disability in the aged. Plaster fixation 
cannot be expected to yield good results consistently and logically in 
more than 65 or 75 per cent, of the cases. 

REFERENCES 

Albee, F. H.: Treatment of Fractures of the Neck of the Femur. J. Florida Med. 
Assn., XVIII, 11, 1931. 

British Fracture Commission: Quoted by Dickson. 

Campbell, W. C. : Fracture of the Neck of the Femur. J. Am. Med. Assn., LXXXI, 
1327, 1923. 

Fractures in and about the Neck of the Femur. Minnesota Med., 

XV, 654, 1932. 

Dickson, F. D.: A Survey of the Management of Intracapsular Fracture of the Neck of 
the Femur. J. Missouri State Med. Assn., XXXII, 481, 1935. 

Fracture Commission of the American Orthopaedic Association: Report of a Com- 
mission Appointed by the American Orthopaedic Association to Study the End 
Results of Intracapsular Fractures of the Neck of the Femur. J. Bone and Joint 
Surg., XII, 966, Oct. 1930. 

Henderson, M. S.: Fractures of the Neck of the Femur, Recent and Old: A Report of 
631 Cases. Southern Med. J., XXVII, 1032, 1934. 

Ununited Fractures of the Neck of the Femur. Western J. Surg., 
XLIII, 134, 1935. 

Fractures of the Neck of the Femur. Minnesota Med., XIX, 147, 

1936. 

Katzenstein: Quoted by Dickson. 

Krida, Arthur: Intracapsular Fracture of the Hip: A New Technic of Operation. 

Surg. Clin. North America, XVI, 727, 1936. 

Leadbetter, G. W.: A Treatment for Fracture of the Neck of the Femur. J. Bone an 
Joint Surg., XV, 931, Oct. 1933. 


THE journal of BONE AND JOINT SURGERI 


FRACTURES OF THE NECK OF THE FEMUR 


115 


fractures of the neck of the femur), but they can be recognized by certain 
signs: (1) a relatively slight deformity, especially a small amount of short- 
ening; (2) the relatively slight amount of pain; (3) the ability of the patient 
to move the leg voluntarily, at least to some degree; (4) occasionally the 
ability of the patient to walk on the leg. 

Whitman’s abduction method of treatment marked a great advance 
solidly based on sound principles, but it has its shortcomings, as is evi- 
denced by the percentage of failures to secure bony union. This is due to 
the inability always to secure perfect fixation of the fragments, even by 
the use of abduction and a plaster spica. A very brief experience with the 
plaster spica will convince one of the impossibility of keeping the hip joint 
completely at rest. So much soft tissue is interposed between the plaster 
and the joint that the patient can move within the plaster, and complete 
immobility of the fracture line is rarely attained. Further, if the knee 
joint is freed for exercise during the period of plaster fixation, the pull 
on the quadriceps, from its origin on the ilium to its insertion in the patella, 
exerts a force which pushes the shaft of the femur upward and sheers across 
the line of fracture, completely disturbing the absolute fixation of the 
fracture which is essential for union. It is this fact which makes reduc- 
tion with the head in valgus and the Schanz osteotomy valuable adjuncts 
of treatment. They alter the relationship between the line of fracture and 
the forces playing upon it, so that the latter are expended in forcing the 
fractured surfaces together instead of sheering one across the other. The 
great contribution which has been made by internal fixation of fractures is 
that it secures adequate fixation of the fracture line and simulates the 
situation which exists in impacted fractures. 

In the past three years the Fracture Service of the Toronto General 
Hospital has treated fifty cases of intracapsular fracture of the neck of the 
femur by internal fixation. The Sraith-Petersen nail is the only form of 
internal fixation which we have used. It has been introduced by various 
methods, chief among which are: open reduction, as practised by Watson 
Jones; insertion along a previously placed Kirschner ware, as advocated by 
Johansson; and the use of a long handle screwed into the nail, as recom- 
mended by White. Broadly speaking, our results have been eminently 
satisfactory. We have encountered some difficulties and some failures. 
The latter have been due to technical problems which will be discussed 
later. Our experience leads us to the conclusion that, after satisfactory’^ 
reduction of a fracture, a Smith-Petersen nail properly placed in the frag- 
ments can be counted upon to secure bony union in every case. In addi- 
tion, the method permits the satisfactory treatment of certain other diffi- 
cult problems, such as ununited fractures of the neck of the femur, in a 
manner not hitherto possible. 

So impressed are we with the value of the method that we believe 
we may accept its success as proved. More is to be gained by discussing 
difficulties and imperfections which lead to poor results. 


VOL. XX. NO. 1. JAXCAUY 193S 



EXPERIENCES WITH INTERNAL FIXATION IN FRESH 
FRACTURES OF THE NECK OF THE FEMUR * 

BY R. I. HARRIS, F.R.C.S. (c), TORONTO, ONTARIO, CANADA 
Associate Surgeon, Toronto General Hospital 

During the past three years, on the Fracture Service of the Toronto 
General Hospital, we have been treating fractures of the neck of the femur 
by internal fixation, and, in general, our experience has been such as to 
make us enthusiastic advocates of this method. Two years ago Dr. 
Kellogg Speed referred to this fracture as “The Unsolved Fracture”. 
Today that opprobrium is almost completely removed, due to the great 
advance in the treatment of this difficult surgical problem by means of 
internal fixation. The method is based on sound principles and, although 
there may be a number of technical problems yet to be solved, the impor- 
tance of the contribution is established, and, in our judgment, it will 
govern the future treatment of these fractures. 

This paper is based upon our experience. It is concerned chiefly with 
certain difficulties which we have encountered, and it is presented with the 
hope that frank discussion of such difficulties may lead to further simplifi- 
cation of methods and improvement in results. 

The principle on which the success of the method is based is a simple 
one, although before the introduction of the Smith-Petersen nail it was 
not clearly recognized. It is this; in a fracture of the neck of the femur, 
as in any other fracture, the fragments will unite if (1) the fracture is ac- 
curately reduced, (2) the fragments are placed in close contact with one 
another, and (3) the fragments are maintained in contact with each other 
without any movement whatsoever during the whole period of healing. The 
last requirement is of incomparably greater importance than the other 
two. If these requirements are attained, union will take place irrespective 
of the problem of the blood supply of the head of the femur. Even though 
the femoral head is deprived completely of its blood supply and undergoes 
complete aseptic necrosis, union will still take place if contact without 
movement is rigidly maintained. A graphic illustration of these principles 
is the observation that truly impacted fractures of the neck of the femur 
will always unite proAuded the impaction is alloAved to remain undisturbed. 
So important is this observation that it has come to be our practice to leave 
impacted fractures undisturbed, as Ave feel that the certainty of union in 
100 per cent, of cases greatly offsets the disadAmntages of any minor degree 
of deformity (usually external rotation). Truly impacted fractures are 
rare (comprising not more than 10 per cent, of all cases of intracapsular 

* Read at the Annual Meeting of the American Orthopaedic Association, Lincoln, 
Nebraska, June 2, 1937. 


114 


THE JOURNAL OF BONE AND JOINT SURGERA 



FRACTURES OF THE NECK OF THE FEMUR 117 



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VOL. XX. NO. 1. JAXUAHY 193S 



116 


R. I. HARRIS 


THE IMPORTANCE OF GOOD ROENTGENOGRAMS 

Our experience would indicate that certain factors are of vital impor- 
tance in the success of the procedure. It cannot be too strongly empha- 
sized that the insertion of the nail is a highly technical procedure, only to 
be undertaken in adequately equipped hospitals and with a perfect co- 
ordination between the X-Ray Department and the operating-room staff. 
This indeed is one of the greatest shortcomings of the method. It can be 
undertaken only in the larger hospitals, and hence a large number of 
patients in rural communities are deprived of the benefits of the procedure. 
Good roentgenograms are essential to success. In the past we have had 

difficulty in obtaining uniformly 
good x-rays, especially in the supero- 
inferior direction. Some of our fail- 
ures, or imperfect results, have been 


Fig. 1-A Fig. 1-B 

Imperfect result due to protrusion of the nail through the anterior surface of the 
head into the acetabulum, the result of poor roentgenograms. 

Fig. 1-A: Anteroposterior view at time of operation. Lateral view taken at this 
time was poor, but seemed to show satisfactor 3 f position of the nail. 

Fig. 1-B : Lateral view eight months after operation, revealing the cause of the 
patient’s pain on weight-bearing and walking. The fragments united in fair posi- 
tion; there was moderate limitation of movement, due to arthritis. The nail was 
removed. 

due to this cause. It is quite possible to accept as good enough the posi- 
tion of the nail on the evidence of a poor supero-inferior roentgenogram, 
onl}’’ to find after a lapse of months that the nail has an imperfect grasp 
on the head or has deidated from the central line of the neck, or has pene- 
trated the head posteriorly or anteriorly and is impinging on the acetabu - 
him. This fault can be eliminated by good supero-inferior x-rays. Such 
should be insisted upon, no matter how much it dela 3 '’S the operation. 
(Sec Figures 1-A and 1-B.) The essential features with which the X-Raj' 




THE JOURN'AL OF BOXE AN'D JOI.N'T .SURGERY 




FRACTURES OF THE NECK OF THE FEMUR 


119 


However, experience with two cases (Figs. 2-A, 2-B, 2-C, 3-A, and 
3-B) convinces us that too early weight-bearing can ruin an otherwise 
perfect operation. We have, therefore, adopted the routine of keeping 
the patient in bed for eight weeks following operation. It may be that in 
certain cases even this period of time is too short for solid union to occur 
and that we should wait for roentgenographic evidences of bony union 
even though to do so would preclude weight-bearing for six months. 
Among surgeons of our acquaintance there is the greatest diversity of 
practice in regard to the time in which weight-bearing is permitted. This 
phase of treatment we feel is not yet quite solved. Longer experience 
will be necessary before definite rules can be laid down. Our first impres- 
sion was that an important advantage in the use of the Smith-Petersen 
nail was the possibility that the patient might walk within a month of the 
time of fracture. It is true that early weight-bearing can sometimes be 
permitted without bad results. This is to be attributed to the rigidity 
with which the nail fixes the fragments, and does not alter the indisputable 
fact that great strain is placed upon the point of mechanical fixation. Any 
imperfection in this fixation will permit movement and mar the results. 
The difference between a perfect result and an imperfect one or a failure is 
so great that eight weeks spent in bed is a small price to pay for it. If at 
the end of an arbitrary period of time, such as eight weeks, any doubt of 
union exists, weight-bearing should not be permitted until roentgeno- 
graphic evidence of union is present. 



Fig. 4 

Smith-Petersen nail of high-chromium, high-nickel, stainless steel but not 
polished. Marked corrosion necessitated removal of nail, although not until 
union had occurred. 


THE IMPORTANCE OF USING NAILS MADE FROAI PROPER STEEL 

A third source of difficulty has been but little stressed. This is the 
quality of the steel which is used for the nails. It is essential that the nail 
be as completely non-irritating as possible. In order to perform its func- 
tion, it must stay in place at least for several months. Should any infec- 
tion or irritation occur during that time, the close association with the hip 
can load to disastrous destruction of the joint. (See Figure 4.) 

Stainless steel is a generic term used to designate anj' alloj’’ of steel 
which resists corrosion, but especiallj’’ those containing nickel and chro- 
mium. There is a verj"" wide variety of these alloj’’s, — they varj' in their 
content of nickel and chromium, in their ability to resist oxidation, in 
their hardness or softness, and in their ability to be tempered. It should 
be emphaticallj'^ stated that not all stainless steels are suitable for use in 


VOL. XX. XO. 1. JAXUAUY 103S 





118 


R. I. HARRIS 


Department must be able to provide the surgeon to ensure success are: (1) 
a portable x-ray machine of adequate power; (2) a technique which will 
give good views of the fracture in two planes — supero-inferior being par- 
ticularly important — and permit successive sets of roentgenograms to be 
compared with each other (this means taking each film from a predeter- 
mined position of tube and cassette); (3) developing facilities within easy 
reach of the operating room, so that the developed films maj"^ be seen quickly. 

THE DANGER OF BEARING WEIGHT TOO EARLY 

The second source of failure is too early weight-bearing. There have 
been one complete and one partial failure in our series from this cause. It 
is remarkable how securely the nail will fasten the fragments together. 
Nevertheless, to bear weight upon the limb before solid union has occurred 
places a great strain upon the fracture line, and this can cause the head of 
the femur to be torn off the end of the nail or to shift its position. A 
striking example of the security of fixation obtained by the nail occurred in 
a mentally deranged woman in whom a fractured neck of the femur had 
been treated by insertion of a Smith-Petersen nail. She got out of bed on 
the second day after operation and from that time on was out of bed walk- 
ing during some part of every day. Three months after operation she 
secured a position as housekeeper and has been able to walk ever since. 
No shift occurred in the fragments and solid union was secured. 




Fig. 3-A Fig. 3-B 

Complete failure from too earl}' weight-bearing (one week after operation). 
Fig. 3-A: Immediately after operation. 

Fig. 3-B: One month after operation. Complete separation of head from neck 
and from nail. 


THE JOURNAL OF BONE AND JOINT SURGERV 




TABLl-; OF CONTENTS 


{Continued) 

PAGE 

Isoi.atki) Pahaeypis 01' THE SEiiHATrs ANTEiuon (Magn'us) Muscle, 

Uy M. Thnmn.s llnnril:, M.D., and Leandro M. Tocantins, M.D., Philadelphia, Pennsylvania . . 720 

TAi!SAi/-.\VEi)Gn AiminonEsis, 

Py Edgar M. JiirJ:, New York, N. Y 726 

Heman'oiomata of the Loweu Exthemities. With Special Referexce to Those of the Knee- 
•Toint Capsule and the Phenomexon of Spontaneous Obliteration. 

Hy James li. llVnirr, M.D., Kans.as City, Missouri 731 

PosTEiuoii Dislocation of the Elbow .Joint Co.mplicated by Fracture of the Medial 
Epico.ndyle and Ulnar-Nerve Injury. 

Py Tom Outland, M.D., and C. R. Hanlon, M.D., Sayre, Pennsylvania 750 

Curare Therapy for the Release of Muscle Spasm and Rigidity in Spastic Paralysis and 
Dy.sto.nia Musculoru.m Deformans. 

■ By Michael S. liurnwn, M.D., New York, N. Y 754 

-Araciinodactylia. a Report of Eight Cases. 

By John R. A'orcross, M.D., Chicago, Illinois 757 

Changes Simulating Legg-Perthes Disease (Osteochondritis Deformans Juvenilis) Due 
TO JUA'ENILE MyXOEDEMA. RePORT OF A CaSE. 

By Fuller Albright, M.D., Boston, Massachusetts 764 

Traumatic Dislocation of the Hip Followed by Perthes’ Disease. 

Bi' Raphael R. Goldenberg, M.D., Paterson, New Jersey 770 

Bilateral Congenital Talonavicular Fusion. Report of a Case. 

By Paul IF. Lapidus, M.D., New York, N. Y 775 

Treat.ment of Birth Fractures of the Femur. 

By IVillon H. Robinson, M.D., Pittsburgh, Pennsylvania 778 

A Cap to Protect the Ends of Steinmann Pins. 

By Robert Mazet, Jr., M.D., Oyster Bay, Long Island, New York 781 

A Leg Holder for Hip Nailing. 

By Robert Crawford Robertson, M.D., Chattanooga, Tennessee 782 

Orthopaedic Surgeon’s Utility and Plaster Cart. 

By Voigt Mooney, M.D., Pittsburgh, Pennsylvania 784 

A Pin and Stirrup for Finger and Toe Traction. 

By Edward N. Reed, M.D., Santa Monica, California 786 

A Bone Plate Which Will Not Break or Bend. {Correction.) 

By George IF. Hawley, M.D., Westport, Connecticut, and Ralph D. Padula, M.D., Norwalk, 

Connecticut "92 

News Notes 787 

Current Literature 

13 



120 


R. I. HARRIS 



THE JOURNAL OF BONE AND JOINT SUnOEnY 




FRACTURES OF THE NECK OF THE FEMUR 


121 


bone work. The mere fact 
that a certain alloy of steel will 
resist corrosion or exposure to 
air is no proof that corrosion 
will not take place when the 
nail is inserted in bone. The 
so-called high-nickel, high- 
chromium alloy has proved 
least irritating and least cor- 
rodible. 

A further point of great 
importance is the manner in 
which the nail is finished, irre- 
spective of the material from 
which it is made. It has been 
proved from the researches of 
Hatfield that the ability of 
stainless steel to resist corro- 
sion is due to the presence of 
a film of chromium oxide on 
the surface of the steel. The 
smoother the surface of the 
steel, the more perfect will be 
this film and the greater the 
powers of resistance to corro- 
sion. Any imperfection or irregularity on the surface may break the film 
and permit corrosion to start. Hence, not only should Smith-Petersen 
nails be made of high-nickel, high-chromium steel, but they should be 
finished with a high polish. This is a point of some importance, since even 
a small area of corrosion may set up sufficient irritation to necessitate 
removal of the nail. 

THE DANGER OF USING NAILS THAT ARE TOO LONG OR OF DRIVING 

THEM IN TOO FAR 

We have encountered difficulty occasionally by inserting a nail com- 
pletely through the head of the femur, either because an overlength nail 
was used or because it was driven in too far. This problem is compara- 
tively simple to solve, but it does stress the importance of choosing a nail 
of the correct length. In both cases in which this complication occurred 
the nail was subsequently removed, because of pain on movement. (See 
Figures 5-A, 5-B, and 5-C.) 

THE VALUE OF SIMPLIFIED METHODS 

The greatest shortcoming of the method, however, is the highly 
technical nature of the procedure necessary to introduce the nail. Smith- 
Petersen’s original technique was of such magnitude that most surgeons 



Fig. 6 

Imperfect result from an overlength nail in- 
serted through head into acetabulum. Painful 
movement necessitated removal one year after 
operation. Good union and good position. 


VOL. XX, XO. 1, JAXUARY 193S 




122 


R. I. HARRIS 


TABLE I 

Results op Internal Fixation by Smith-Fetersen Nail in Fifty Cases of Fracture 
OF THE Neck of the Femur Treated at the Toronto Hospital 


Result 

No. of Cases 

Per Cent. 

Good: 

Solid union and good function 

36 

72.00* 

Imperfect: 

Solid union, but poor function 

Nail too long in both cases 

2 

4.00 

Failure: 

Sepsis — 1 case 

Too early weight-bearing — 4 cases 

Pin inaccurately placed — -2 cases 

7 

14.00 

Death : 

Sepsis in wound — -1 case 

Pulmonary embolus — 3 cases 

5 

10.00 

Cardiac failure— 1 case 




* Good results were obtained in 80 per cent, of the surviving patients. 


hesitated to use it on elderly patients who were poor risks. The great 
stimulus to the use of internal fixation came with the introduction of 
simpler and less traumatizing methods, especially that of Johansson. 
Even this and the further modifications of Watson Jones, White, 
and others still demand such a high degree of technical skill and per- 
fection of equipment that the application of the method is limited. It 
cannot be undertaken except in hospitals which have adequate equipment, 
and relatively few have the desired armamentarium. It demands perfect 
coordination between a skilled X-Bay Department and the operating- 
room staff. The equipment and facilities of smaller hospitals are apt to 
be inadequate and, therefore, preclude the surgeon from opei’ating “out 
of town ”, and the patients will not stand transportation for long distances. 
Finally, it can only be done with success by a surgeon who is thoroughly 
familiar with bone surgery and the surgery of the hip joint; it emphatically 
is not an operation to be performed by the occasional surgeon, or the gen- 
eral surgeon, or, indeed, by anyone not skilled in orthopaedic surgery. 
These factors greatly limit its application. It is most desirable to achieve 
further simplification of the method of introducing the nail, so that the 
method can be more widely applied. Until then, we should not abandon 
the simpler and more widely applicable abduction treatment of Whitman. 

COMMENT 

It only remains to be stated that nearly all our failures occurred in the 
earlj^ period of our use of this form of treatment. Furtlier experience has 

the journal of bone and joint surgery 



FRACTURES OF THE NECK OP THE FEMUR 


123 


enabled us to insert the nail with increased speed and facility and with 
greatly diminished disturbance to the patient. Our experience leads us to 
believe that, after satisfactory reduction of a fracture, a nail properly 
placed in the fragments will ensure union in practically every case in 
greatly diminished time and with great improvement in function. Inter- 
nal fixation of fracture of the neck of the femur marks a great advance in 
treatment. Our present attitude is that all fractures of the neck of the 
femur can best be treated by internal fixation. 

REFERENCES 

Hatfield, W.: Trans. Inst. British Surg. Technicians, I, 1936. 

Speed, Kellogg: The Unsolved Fracture. Surg. Gynec. Obstet., LX, 341, 1935. 


VOL. XX, NO. 


JANUARY 193S 



DASHBOARD DISLOCATION OF THE HIP 
A Report of Twenty Cases of Traumatic Dislocation * 

BY ROBERT V. FUNSTEN, M.D., PRENTICE KINSER, M.D., AND 
CHARLES J. FRANKEL, M.D., CHARLOTTESVILLE, VIRGINIA 

From the Orthopaedic Clinic of the University Hospital, Charlottesville 

The name "dashboard” dislocation of the hip has been chosen 
because it points out the means by which most of the patients upon 
whose cases this paper is based received their injuries. The person so 
injured was usually sitting beside the driver of an automobile when it 
came to an abrupt stop in a collision. In such a case, since the hip is in 
a flexed and adducted position, the force of the impact of the tibia or of 
the knee against the panel is transmitted through the femur to the 
posterior rim of the acetabulum, and the result may be a simple dis- 
location or a dislocation with fracture of the lip of the acetabulum. 
Occasionally a fracture of the tibia or of the patella is experienced 
instead. 

This mechanism was the cause of dislocation in thirteen of the 
twenty cases here reported. In the remaining seven, two patients were 
thrown out of automobiles; two were struck by automobiles; one patient 
fell from a tree; one fell from a box car; and one was injured at birth. 

The routine method of treatment in the fresh cases was immediate 
closed reduction, followed by traction of the Russell or Buck type. If 
there was a formidable fra,cture of the acetabulum, the traction was 
maintained for a period of approximately eight weeks. If, however,- no 
acetabular fracture existed, the period of traction lasted only from two to 
three weeks. During the period of traction in both instances, active 
motion was maintained in the knee and the hip joints. 

Treatment of the old cases required much more active correction, 
and the results were discouraging, as shown in Table I. 

A brief description of these twenty cases is contained in Table I. The 
findings may be summarized as follows: 

1. The age range of the majority of these patients was between 
twenty-three and fifty years. 

2. There were thirteen males and seven females. 

3. Thirteen of the patients were injured while they were riding 
as passengers in automobiles; in ten of these cases the right hip was 
dislocated. 

4. The average period of obsei'vation was three years. 

5. In the three cases in which operations were performed the average 
period between injury and treatment was eight months. 

* Read at the Annual Meeting of the American Orthopaedic Association, Lincoln, 
Nebraska, June 3, 1937. 

124 


THE JOURNAL OF BONE AND JOINT SURGERY 



DASHBOARD DISLOCATION OF THE HIP 


125 


6. In eleven cases the end results were good; in two, fair; in five 
(including the three cases in which operations were performed), poor; 
and in two, undetermined. 

7. In six cases there was absorption of the head. 

8. In seven cases there was an uncomplicated posterior dislocation ; 
in one, an uncomplicated obturator dislocation ; in one, an obturator dis- 
location with an incomplete fracture of the neck; in two, fracture of the 
neck and posterior dislocation; and in nine, posterior dislocation compli- 
cated by fracture of the acetabulum. 

COMMENT 

The following case is typical of the injury under discussion and shows 
the result when treatment is delayed. 

Case 15. R. S., a boy, aged thirteen, was riding beside the driver of a roadster when 
the car hit an abutment and overturned. After a brief period of confusion, he got up 
and hobbled to another car. When he reached his home, the family physician was 
called. There was evidence of contusion about the right hip, but no shortening or 
apparent deformity. No roentgenographic examination was made at the time. The 
boy continued to complain of pain and swelling in the region of the hip, and three weeks 
after the injury a roentgenogram showed a complete posterior dislocation of the head of 
the femur (epiphyseal separation), but the neck had sprung back into the acetabulum. 
Because of the boy’s age, an open reduction was done and, after much difficulty, the 
head was replaced on the neck and then put back into the acetabulum. The head was 
maintained in its position by means of an ivory peg. Aseptic necrosis of the head took 
place. Observation five years after injury (Fig. 1) showed shortening of one and one- 
quarter inches. The ability to abduct and to rotate was greatly limited. However, in 
spite of the limp, the boy was free from pain and took part in such athletics as tennis 
and golf. 

Two similar cases 
(Cases 2 and 19) were 
treated more recently, 
with poor results. 

(See Figures 2, 3, 4, 5, 
and 6.) 

Miltner and Wan 
reported a series of 
sixteen cases of hip 
dislocation of long 
standing in which re- 
duction was accom- 
plished in twelve with 
a fair percentage of 
good results. The 
anterior incision of 
Smith-Petersen was 
used in all but one 
case. However, our 
experience has caused 



Fig. 1 

Case 15. Epiphyseal-separation dislocation, five years 
after open reduction, showing neck in acetabulum. 


VOL. XX. XO. 1. JAXC.VnV 193S 


TABLE I 

Twenty Cases op Traumatic Dislocation op the Hip 


126 


R. V. FUNSTEN, P. RINSER, AND C. J. FRANKEL 



THE JOURNAL OF BONE AND JOINT SURGERV 














































128 


R. V. FUNSTEN, P. KINSER, AND C. J. FRANKEL 



Fig. 2 

Case 2. Posterior fracture-disloca- 
tion of the head of the fenuu’; neck in 
acetabulum. 



Fig. 3 

Case 2. Ten months after injurj'. 
Full range of flexion. Adduction and 
rotation limited. 


US to feel that such an incision creates too great a handicap to the proper 
shelving of the posterior portion of the roof of the acetabulum. 

An analogous case was I’eported by Henry and Bayumi. The proxi- 
mal portion of the femur of a woman sixty years of age was removed and 
the neck was inserted into the acetabulum. These authors stated that 
three inches of shortening resulted, but they did not mention the range of 
motion. 

Platt pointed out the danger of injury to the sciatic nerve and of frac- 
ture of the neck of the femur when manual reduction is attempted more 
than a few weeks after dislocation. If uncontrollable bone fragments are 
present at the time of manual reduction, he felt that their removal at oper- 
ation, six to eight weeks after reduction, improves motion and lessens pain. 

Bunne reported a good result in his case, that of a woman forty-four 
years old, after open reduction of an obturator dislocation, in spite of the 
presence of myositis ossificans and of some necrosis of the head. 

Six of our cases demonstrated the possibility of development of 
aseptic necrosis, as described by Phemister and by Dyes. Two of tlie 
cases reported by Dyes showed changes almost identical with those seen 
in Legg-Perthes disease. Apparently injury to the nutrient arteiics of 
the neck is necessaiy, in addition to rupture of the ligamentum teres, for 
the development of severe necrotic changes. 

THE JOURXAE OF BON’E AXD JOI.VT SERGEBY 





VOL. XX, XO. 1. JAXUAUY 193S 


CiiM' 19. Di.'ilociition unreduced, fifteen month.s Case 19. Five weeks after operation con- Case 19. Three months after opera- 
after injury. sisting of open reduction, decapitation, and tion. 

replacement of the neck in the acetabulum. 




130 R. V. FUNSTEN, P. KINSER, AND C. J. FRANKEL 

Stewart reported 
a case of simple dislo- 
cation in which good 
recovery was appar- 
ently being made at 
the end of two months, 
but, at the end of five 
months, there was in- 
creasing limitation of 
motion because of the 
gradual development 
of ossification in the 
capsule and breaking 
down of the head. The 
head later became 
transformed, but at 
the expense of motion. 

This type of degen- 
erative change in the 
joint took place in one 
of the cases (Case 14) 
of this series. 

Case 14. D. S., a physician, aged forty'eiglit, received a dislocation of the right hip 
with a fracture of the posterior rim of the acetabulum. Good recovery of function was 
apparently taking place, but, at the end of four or five months, increasing lameness and 
pain in the hip developed. Roentgenographic examination showed partial absorption 
of the head with calcification of the capsule. Transformation gradually took place in the 
head, but, on observation six years after injury, the patient showed marked limitation of 
motion of the hip, walked with a decided limp, and had pain. 

Our youngest patient (Case 17), a new-born boy, received a trau- 
matic dislocation as a result of podalic version in delivery. This case 
has been included in the series with apologies to the “dashboard syn- 
drome”. The dislocation was upAvard and backward and was easily 
reduced under a very short anaesthesia. A cast Avas applied from the 
toes to the chest for a period of ten days, and no further treatment was 
gh^en. The patient Avgs reexamined fiAm years later, and the hip Avas 
apparently normal in eAmry respect. 

Such dislocation in children is rare, but cases haAm been reported by 
Glynn, and Mauck and Andei’son. The only other child AA'^ho came 
under our obsexwation Avas a colored boy, aged eight (Case 11). Goetz 
reported a traumatic dislocation of the hip into the scrotum occurring 
in a boy ten years of age, and Campbell reported a perineaj dislocation 
in a boy of eleA’'en. 

Tayo of our patients (Cases 9 and 16) had obturator dislocations. In 
one case (Case 9), the dislocation AA-as uncomplicated by fracture (Fig. 7 ). 
In the other (Case 16), a large chip AA-as torn loose from the upper surface 



Fig. 7 

Case 9. Uncomplicated obturator dislocation. 


THE JOURNAL OF BONE AND JOINT SURGERY 




VOL. XX. XO. 1. JANUARY 193S 







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14 


THE SPASTIC HAND 


BY MICHAEL S. BURMAX, M.D., NEW YORK, X. Y. 

From the Hospital for Joint Diseases * 

The surgeiy of the spastic hand is neglected. This has been einpha- 
' sized by BrockwajL In a studj'’ of 1000 spastic children, on whom 542 
operations had been done, the author found that the upper extremity 
itself received surgical attention only sixty-five times. The hand, exclu- 
sive of the wrist, was operated upon ten. times, nine of the operations being 
directed at the oppositional deformity of the thumb. 

This study is the result of clinical observation on the effect of curare 
in spastic paralysis. It includes the study of persistent spastic opposition 
position and contracture of the thumb, with or without flexion of the ter- 
minal phalanx of the thumb ; spastic adduction contracture of the thumb ; 
spastic intrinsic lij’^perextension of the fingers; spastic flexion-abduction 
position of the fingers; and, finall}’', spastic anterior subluxation of the 
first metacarpal head. A solution Avas sought for every hand deformitj’- 
which did not jdeld to curare or hindered its effects. It is to be empha- 
sized that this is not a final study of end results, since the period of post- 
operative observation is too short. Most of the cases haA'^e been folloAA^ed 
for at least a 3 ’'ear after operation. 

PERSISTENT SPASTIC OPPOSITION POSITION OF THE THUMB, WITH OR WITH- 
OUT FLEXION OF ITS TERMINAL PHALANX 

The thumb is draAvn into the palm in constant or inconstant position 
in opposition by the action of the three muscles whose fleshy bellies to- 
gether make the thenar eminence, — the opponens pollicis, the fle.xor pol- 
licis breA'is, and the abductor pollicis brcAUS. 

The hand encloses the thumb, and it becomes impossible to grasp aii}’^ 
object, either passiA^ely or actiA'ely. In mobile siiastics, the passive 
stretching of the extensors of the thumb in palmar flexion of the Avrist 
sometimes forces the thumb out of the hand, but it reenters the palm on 
dorsiflexion of the Avrist. This is not invariably true, and the thumb maA’- 
be retained in the palm eA'en though the Avrist is in palmar flexion. 

The index and middle fingers are sometimes placed more dorsalty 
than the ring and little fingers, because of the indraAA'ing of the thumb, 
In the presence of frequent spasm of the index finger, the skin OA'er the 
dorsal aspect of the metacarpophalangeal joint of the thumb maj'- become 
excoriated and keratotic. Dissociated action of the thenar muscles some- 
times exists. The thumb is not opposed. The first metacarpal bone is 
abducted bj- the abductor pollicis longus, and the thumb is flexed at the 
metacarpophalangeal joint bj^ the flexor pollicis brcA'is, the terminal 
phalanx being hj'pcrextended. 

* Service of Leo Mayor, M.D. 

VOI., X.\, xo. 1. .I.\NT.\nY I9.AS Ei-'i 



132 


R. V. FUNSTEN, P. KINSER, AND C. J. PRANKED 


of the neck, which had apparently been avulsed by the capsule when it 
became detached (Figs. 8 and 9). Such cases seem to be subject to 
aseptic necrosis. 


CONCLUSIONS 

1. The immediate reduction gnd traction treatment of uncom- 
plicated dislocation of the hi]) gives uniformly good results. 

2. When the dislocation is accompanied by a formidable fracture, 
the prognosis should be guarded, because of the possibility of develop- 
ment of aseptic necrosis and periarticular ossification. 

3. The longer the hip stays out of place the poorei' are the prospects 
of obtaining a satisfactory result by operation. 

REFERENCES 

huNNE, F.: Zur Behandlung der veralteten Lu.vatio traumatica des Hiiftgelenks. Zen- 
tralbl. f. Chir., LXIII, 194, 1936. 

C.A.MPBELL, W. C. : Perineal Dislocation of the Hip witii Avulsion of tlie Greater Tuber- 
ositjn J. Am. Med. Assn., LXXVIII, 1115, 1922. 

Dyes, Otto.: Hiiftkopfnekrosen nach traumatischer Hhftgelenksluxation. Arch. f. 
klin. Chir., CLXXII, 339, 1932. 

Glynn, Philip.: Two Cases of Traumatic Dislocation of tlie Hip in Children. Lancet, I, 
1093, 1932. 

Goetz, A. G. : Traumatic Dislocation of the Hip (Head of the Femur) into tlie Scrotum. 

J. Bone and Joint Surg., XVI, 718, Jub^ 1934. 

Henry, A. K., and Bayumi, M.: Fracture of the Femur with Luxation of the Ipsilateral 
Hip. British J. Surg., XXII, 204, 1934. 

LePage: Luxation de la hanche avec fracture du sourcil cot 3 'loidien chez une femme de 
soixante-cinq ans. Bull, et Mdm. Soc. de Chir. de Paris, XXVI, 28, 1934. 

Mauck, H. P., and Anderson, R. L. : Infracotyloid Dislocation of the Hip. J. Bone and 
Joint Surg., XVII, 1011, Oct. 1935. 

Miltner, L. j., and Wan, F. E.: Old Traumatic Dislocation of the Hip with Special 
Reference to the Operative Treatment. Surg. Gynec. Obstet., LVI, 84, 1933. 
Phemister, D. B.: Fractures of Neck of Femur, Dislocations of Hip, and Obscure 
Vascular Disturbances Producing Aseptic Necrosis of Head of Femur. Surg. 
Gjmec. Obstet., LIX, 415, 1934. 

Platt, Harry: On Some Complications of Traumatic Dislocation of the Hip-Joint. 
British J. Surg., XIX, 601, 1932. 

Stewart, W. J.: Aseptic Necrosis of the Head of the Femur Following Traumatic Dis- 
location of the Hip Joint. Case Report and Experimental Studies. J. Bone and 
Joint Surg., XV, 413, Apr. 1933. 


THE JOURNAL OF BONE AND JOINT SURGERY 



THE SPASTIC HAND 


135 


flexor carpi radialis to the ex- 
tensor pollicis longus to secure 
active abduction of the 
thumb. He also shifted this 
same tendon to the abductor 
pollicis longus, together with 
one-half of the extensor carpi 
radialis, for the same purpose. 

The Stoffel operation has been 
recommended not only by 
Stoffel but by other authors, 
such as Gill and Heyman. 

This operation is not now 
usually done, but Brockway 
does a complete or partial re- 
section of the nerve supply to 
the opponens pollicis or flexor 
pollicis brevis, with a fair end 
result. 

Foerster and, later, Silf- 
verskiold did a tenomyotomy 
of the muscles which termi- 
nate on the ulnar sesamoid of the thumb, or a myotomy of the opponens 
pollicis. The adductors seem to have been cut also. Silfverskiold used 
this method with good results. This operation is comparable to the one 
which the author is describing, but both Foerster and Silfverskiold placed 
undue emphasis on the adductors of the thumb. The writer’s plan of 
operation was independently conceived and only in the investigation of 
the literature did he come upon their work. 

The aim of the operation is the lessening of the leverage which the 
spastic muscles exert on the thumb by the stripping of the common tendon 
of insertion, with or without plastic lengthening of the flexor pollicis 
longus at the wrist. 

The operation should be a final procedure rather than an initial one, — 
final in the sense that other operations, such as tendon transplantation at 
the wrist, precede it. This is so for two reasons: First, we must allow the 
spastic hand enough time for readjustment after an operative procedure to 
determine how much has been gained and what is next needed; second, the 
position of the thumb may change in vaiying positions of the wrist. The 
operative procedure for the thumb cannot be carried out until the final 
position of the wrist is determined. This is not so easj', since many spas- 
tics use their fingers better in palmar flexion of the wrist. 

Operative Technique 

Tlic operation is best done under local anaesthesia. The inctsion is 
longitudinal, placed on the anterior radial border of the tlnmib, and 



Fig. 1-B 

Case G. W. The appearance of the thumb 
after operation. 


VOL, XX, xo. 1, J.\xrAnY iras 



134 


M. S. BURMAN 


The terminal phalanx of 
the thumb is often flexed by 
spasm of the flexor pollicis 
longus. This flexion in- 
creases the positional deform- 
ity of the thumb. The flexor 
pollicis longus acts in the 
manner of a bowstring as a 
secondary opponens of the 
thumb. The thumb exe- 
cutes its final position of op- 
position easily with flexion of 
the terminal phalanx. Op- 
position is more difficult in 
extension of the terminal 
phalanx, and, in the normal 
hand, strain is felt in the 
short muscles of the thumb in 
this position. In some spas- 
tic thumbs, flexion at the 
metacarpophalangeal joint of 
the thumb with extension of 
the terminal phalanx is seen. 
This is comparable to the intrinsic-muscle position of a finger. The flex- 
ion of the basal phalanx is due to action of the flexor pollicis brevis; the 
extension need not be an active extension, but may be passive by pull of 
the fascial band which passes from the abductor pollicis brevis to the ex- 
tensor pollicis longus. Opposition position of the thumb is not as 
marked in terminal-phalanx extension. 

The 'position in opposition can in time become contracture in opposi- 
tion. The author has noted this twice. This contracture in opposition is 
present only in the older spastics in whom the deformity has existed for 
many years. The atrophied muscles have long ceased to respond to 
hyperinnervational impulses. The first metacarpal bone is drawn in 
front of the second metacarpal and is more or less immovable in that posi- 


Fig. 1-A 

Case G. W., female, aged twenty-two, showing 
the spastic indrawing of the thumb. This case 
is not described in the text. 



tion, not only by muscle conti’acture but also by contracture in the carpo- 
metacarpal joint of the thumb. An unusual complication is medial rota- 
tion of the thumb by pull of the thenar muscles, when a fixed anterior 
subluxation of the first metacarpal head exists. The thumb is so twisted 
that the nail faces the palm and the pulp of the thumb faces outward. 

There have been many operative attempts to correct persistent op- 
position position of the thumb. Dowd noted that Hoffa shortened the 
extensor pollicis longus. This operation is comparable to the tendon 
transplantation of Bicsalski and Mayer, in which the e.xtensor indicis 
proprius is attached to tlie long extensor of the thumb. Viilpius and 
Stoffel shortened the abductor pollicis longus. Hoffa transplanted the 


TIIK JOURNAL OF BONE AND JOIN'T .SURGERY 




THE SPASTIC HAND 


137 



Fig. 2-A Fig. 2-B 


Case A. O., female, twentj'-four 3’ears Case A. 0., after operation. A flex- 

of age, before operation. ion position of the terminal phalanx of 

the thumb has recently developed. 

possible. However, as a rule, the The thumb is kept out of the palm, 
operation gives no active power of 

abduction unless the abductor pollicis longus has some strength. If a 
tendon transplantation which will give abduction can be done, it should be 
done in combination with the operation of thenar stripping. A good 
result may be expected if the transplanted tendon has actual power; usu- 
ally, the transplant is paretic. The appearance of the hand after thenar 
stripping is nearer the normal and the thumb no longer falls into the palm. 
It is maintained at the side of the hand somewhat ahead of the fingers. In 
the irritable spastics, the thenar muscles contract as frequently as before 
operation, but, since the insertion point has been lowered, they do not 
draw the thumb into the palm. 

There has been no recurrence of deformity in any of the cases in which 
the operation has been done. 

Certain minor complications must be avoided. If the joint capsule is 
opened, there may develop slight restriction of flexion of the metacarpo- 
phalangeal joint of the thumb with pain over its anterior capsule. This 
may persist for several months. If the thumb is immobilized in too much 
extension, a slight anterior subluxation of the first metacarpal head may 
take place. In a mobile spastic hand, a mild degree of valgus de^dation of 
the thumb may come about. 

A long period of physiotherapy follows the operation and this is sup- 
plemented sometimes with curare. Hand exercises are beneficial. 

Ilhislrative Cases 

T. G., a girl of nineteen, had a left hemiplegia of sj'philitic etiologj'. The loft hand 
showed spastic indrawing of the thumb with terminal-phalanx flexion. The fingers were 
clenched over the thumb. The wrist was acutely flexed. The hand showed no active 
power. Tlienar stripping of tlie left thumb, with lengthening of the flexor pollicis longus 
at the wrist, was first done, followed several months later b3' lengthening of the wrist 
fle.xors. 

The period of observation has been more than a 3'car. There still is no active power 
in tlio hand. The thumb is out of the p.alm and shows no tondenc3- to be drawn into it. 
It rests usualb' at the side of the hand and a little in front of it. The terminal phalanx of 

VOI., XX. XO. I. JAXUAnV I!13S 



136 


M. S. BURMAN 


extends from one-half an inch above the point of thenar insertion down 
along the length of the shaft of the first metacarpal bone. The superficial 
branch of the radial nerve is avoided. The opponens pollicis is stripped 
subperiosteally from the shaft of the first metacarpal. The common ten- 
don is exposed as it inserts diagonally on the ijrominent tubercle on the 
outer side of the first phalanx. The tendon is severed from its point of in- 
sertion and stripped proximally for at least three-quarters of an inch. It 
is important that the most ulnar part of the tendon, contributed by the 
flexor pollicis brevis, be severed. The capsule of the metacarpophalan- 
geal joint may be cut if contracted, and the joint may be opened. The 
common tendon, which is from one-half to three-quarters of an inch long, 
is excised after it has been stripped. The wound is closed in layers. The 
thumb is immobilized in abduction and extension in the plane of the hand 
for three weeks. 

Plastic Lengthening of the Flexor Pollicis Longus at the Wrist 

It is simplest to lengthen the tendon at the wrist, above the tendon 
sheath and near the musculotendinous junction. The tendon can be 
picked up through a one-inch longitudinal incision above the wrist joint. 
The tendon of the flexor carpi radialis acts as a guide. It is not necessary 
to isolate the median nerve, although the author has done so. The tendon 
is deep in the wrist, and is a peculiarly elusive tendon to find. It lies 
about midway between the tendon of the flexor carpi radialis and the pro- 
nator quadratus; it is nearer the former than the latter. It is lengthened 
by a Z-shaped incision, the ends being secured by a Bunnell-Mayer stitch. 
The wound is closed in layers. 

In the presence of very marked spasticity, the question of how much 
to lengthen this tendon becomes a matter of judgment, especially in spas- 
ticity of the intermittent, surging type. It is better to lengthen the tendon 
too little than too much. The reverse deformity of spastic hyperextension of 
the thumb is brought about, and, in the period of irritability following the 
readjustment of the spastic hand, the overactive and unopposed extensors 
of the thumb can cause a forward subluxation of the head of the first meta- 
carpal. This complication is prevented by immobilization of the thumb 
in slight flexion. When this complication is present, a splint, holding the 
thumb in abduction and in slight terminal flexion, with pressure dorsally 
against the anteriorly protruding metacarpal head, should be applied as 
long as necessary. This complication is ultimately overcome in full or in 
part by readjustment of the flexor-extensor balance. 

The author has done the operation of thenar stripping eight times. 
A ninth case was done on the service of Dr. Finkelstein, in which, in 
addition to thenar stripping, the flexor carpi radialis was transplanted 
to the abductor pollicis longus. The result is too recent to estimate 
yet. 

The patient may be able to abduct the thumb actively immediately 
after the operation, whereas before operation this action had never been 


THE JOURN'AL OF BON’E AXD JOIN’T SURGERY 



THE SPASTIC HAND 


139 


proximal interphalan- 
geal joints in exten- 
sion. The spasticity 
is uneven and is great- 
est in the thumb ad- 
ductors, or it may be 
an isolated expres- 
sion of ulnar-nerve 
spasticity. 

The disability re- 
sulting from adduc- 
tion contracture is 
twofold. The thumb 
cannot be abducted 
in the plane of the 
hand to encircle an 
object. The tight ad- 
ductors restrict the 
ability of the thumb 
to oppose, so that it 
may be po.ssible only 
to bring the thumb to 
the index finger. 

The contracture is 
quite uncommon, but 
probably more com- 
mon than is .su.spected. 
The author has found 
only one reference to 
this condition. Vul- 
pius and Stoffel have 
noted that in adduc- 



Fig. 3-B 


Case S. E., after operative correction of the deformitj’ 
of the thumb. The voluntarj' abduction is shown above, 
adduction below. 


tion contracture of 

the thumb an open section of the adductors is to be done. The adductors 
are approached by a volar transver.se incision. 


Operative Techn ique 

X longitudinal incision is made, running parallel to the shaft of the 
first metacarpal bone along its ulnar border. It extends about one-half an 
inch above the tubercle insertion of the adductors and runs the entire 
length of the metacarpal. The tendon of the e.xtensor jiollicis longus is re- 
tracted laterallj" in the outer margin of the wound. A digital branch of 
the radial nerve, which courses obliquelj' upward and medially from tiie 
lower angle of the wound, is avoided. The first dorsal interosseous muscle 
is stripped subperiostcally from the shaft of the first metacarpal. The 
combined tendon of insertion of the two adductors is seen in the bottom of 


voi.. XX. xo. T, jAxr.\nY 


138 


M. S. BUBMAN 


the thumb is held in about 
5 degrees of flexion. There 
is no tendency to reverse 
deformity of hyperexten- 
sion of the terminal pha- 
lanx of the thumb, since 
the extensors have neither 
intermittent spasm nor 
power. The wrist is held 
in 160 degrees of palmar 
flexion. The fingers re- 
spond to continuous stretch- 
ing, but become flexed 
again after release of the 
stretching force. The ap- 
pearance of the hand is 
improved from a cosmetic 
standpoint, although there 
is very little functional use 
of the hand, 

A. 0,, female, twenty- 
four years old, had a fixed 
opposition contracture of 
the right thumb of many 
years’ duiution. (See Fig- 
ure 2-A.) The thumb 
could be passively ab- 
ducted a little, but this 
caused an anterior sub- 
luxation of the first meta- 
tarsal head. 

On May 13, 1936, the 
deformity was corrected 
by the stripping operation 
with the addition of a 
capsulotomy of the carpo- 
metacarpal joint. 

The patient was last 
seen in November 1936. 
The thumb rested at the 
side of the hand just antei'ior to the palm. Flexion of the terminal phalanx of the 
thumb was developing and was a little troublesome, since the thumb got in the way 
of the index finger. (See Figure 2-B.) The flexed wrist had been arthrodesed. 

SPASTIC ADDUCTION CONTHACTUEE OP THE THUMB 

Adduction contracture of the thumb is due to contracture of the first 
dorsal interosseous muscle and the adductor pollicus obliquus and the 
adductor pollicis transversus. Jt is a contracture in the plane of the hand, 
and the thumb does not lie anterior to the palm. It represents expression 
of increased spasticity in the area of distribution of the motor branch of 
the ulnar nerve. It may thus be coincident with an intrinsic position of 
the fingers, the metacarpophalangeal joints being in flexion and the 



Fig. 3-A 

Case S. E., male, sixteen years of age, showing spastic 
adduction contracture of the left thumb. The power of 
voluntary abduction is illustrated above, that of voluntary 
adduction below. 


THE JOUUXAl. OF BOXE AXD JOIXT SURGEUY 




The Journal of 
Bone and Joint Surgery 

The Official Publication of the 
American Orthopaedic Association 
British Orthopaedic Association 
American Academy of Orthopaedic Surgeons 
Owned and published by the American Orthopaedic Association 
•Title registered in United States Patent Office 


VOL. XX, No. 4 


October, 1938 


Old Series 

VOL. XXXVI, No. 4 


Editor, E. G. Brackett, M.D. Assistant Editor, Florence L. Daland 
BOARD OF ASSOCIATE EDITORS 
Z. B. Adams, M.D. Leo Mayer, M.D. 

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iS, Ladybarn Crescent, Fallowfield, Manchester 14, England 

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Published quarterly: January, April, July, and October 
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THE JOURNAL OF BONE AND JOINT SURGERY 

8 The Fenway, Boston, Massachusetts, U. S. A. 


140 


M. S. BTJRMAN 


the distal part of the wound. Section of the tendon between clamps is 
carried close to the bone. This overcomes the adduction contracture. 
Care should be taken in section of the adductors, since just anterior to 
them and separated from them by a thin but distinct fascial plane lies the 
principal artery of the thumb. The long flexor of the thumb is still more 
anterior. The wound is closed in layers and the thumb is immobilized in 
full abduction in the same plane of the fingers. Gauze-pad pressure is 
made anteriorly and posteriorly to the web of the thumb to prevent post- 
operative hematoma. Immobilization is maintained for about three 
weeks, when exercises are begun. 

The author has corrected adduction contracture of the thumb in two 
cases. In one, the intrinsic-muscle imbalance * of the fingers was absent, 
and in the other it was so slight that resection of the motor division of the 
ulnar nerve could not be considered. The result in both cases was good. 
Active abduction and adduction Avere attained. There is early reforma- 
tion of the adductors, eAmn at three Aveelcs after operation, so that inability 
to adduct the thumb need cause no worry. Thenar opposition was still 
limited in one case; in the other it was good. 

Illustrative Case 

S. E., a bo 3 ^ of si.vteen, showed an adduction contracture of the left thunab (Fig. 
3-A). Abduction of the thumb in the plane of the hand was greatty lessened. On Au- 
gust 14, 1935, under general anaesthesia and witli tlie use of the tourniquet, the operative 
release of the deformity was done. The postoperative course was uneventful, and the 
wound healed -per primam. (See Figure 3-B.) The patient was seen last on May 9, 
1936. Good adduction and abduction of the thumb, especiallj’’ passively, were present. 
Reformation of the adductors had taken place, so that the power of adduction of the 
thumb was not lost. The patient demonstrated a mild intrinsic position of the fingers. 

SPASTIC HYPEREXTENSION OF THE FINGERS IN 
INTRINSIC-MUSCLE IMBALANCE 

Hyperextensioii of the proximal and distal interphalangeal joints is 
associated Avith flexion of the metacarpophalangeal joints in intrinsic- 
muscle imbalance. In extensor spasm, AA^hich is not usual, there is exten- 
sion of the fingers also, but extension, rather than flexion, at the meta- 
carpophalangeal joints. It is not uncommon to obseiwe the intrinsic 
position in mobile spastics, but this position is a changing one. Fixed de- 
formit3'’ can occur, and for this Steindler resected the motor branch of the 
ulnar nerA^e. The aA''erage spastic hand seldom exhibits that great degree 
of hyperextension sufficient to Avarrant oi^erathm interference. Not eAmry 
hand in spastic intrinsic imbalance is useless, for a mild degree may alloAV 
actNe hand poAver and require no operation. The degree of deformity of 
this type of hand maj’’ fluctuate, or the deformity may shift inteimiittently, 

* The term “intrinsic-muscle imbalance” refers to an imbalance existing between 
the extrinsic and intrinsic muscles, in fuAmr of the intrinsic muscles. The fingers assume 
a nosition of flexion at the metacarpophalangeal joints and extension at the interpha- 
Inno'eal joints. Abduction or adduction of the fingers maj' be present in the intrinsic 
position, depending on the preponderance of power in either dorsal or volar interossci. 

THE JOURN'AL OF BOKE AND JOINT 8UROERA' 



THE SPASTIC HAND 


141 


SO that the fingers ma}’’ be clenched or extended. The obliquely coursing 
collateral extensor tendons stand out as taut bands beneath the skin in 
intrinsic or extensor spasm. The wrist is palmarly flexed or fused in 
dorsal position, or it alternates between dorsiflexion and palmar flexion. 
No “pill roller” hand was observed, and the observation of Steindler that 
the deformity can only exist in dorsiflexion could not be substantiated. 
Spastic intrinsic-muscle imbalance was present in hands whose wrists 
Avere either dorsally or palmarly flexed, although the intrinsic-muscle po- 
sition is more easily taken in dorsiflexion of the Avrist. 

The operatiA'e procedure consists in the proximal stripping of the col- 
lateral extensor tendons to the mid-part of the first phalanx, a point well 
beloAv the hyperextended joint. The common extensor tendon must be 
cut transA^ersely or lengthened, for, if this is not done, recurrence of the 
extension deformity Avill take place. There is a certain sympathy in 
spastic hands by Avhich an operatwe procedure directed at one point 
diminishes spasticity at another point. The author, therefore, has con- 
fined the operation to the usually more seA'^erely affected index and middle 
fingers, belleAung that release of hyperextension of these fingers Avould 
diminish the hyperextension of the fourth and fifth fingers. Clinically, he 
has noted that hyperextension is greatest in the index finger and dimin- 
ishes progressiA'ely to the little finger. 

The stripping must be thorough. If it is incomplete, an unusual 
position of the finger is assumed. The proximal interphalangeal joint 
goes into a lesser hyperextension than before operation, while the terminal 
phalanx is flexed because of the action of the now stronger flexor profundus 
tendon. This is a position Avhich can only be assumed Amluntarily by a 
normal finger as a trick motion. The index finger may rest in a plane 
higher than the middle and other fingers after operation. The Avriter be- 
lieA'es that this is due to the presence of tAAn extensor tendons to the index 
finger. He has obserA^ed only once the little finger of a spastic hand in a 
plane higher than the ring and middle fingers; it Avas on a line equal Avith 
the index finger. 

The proper end result should be a more eA’^en balance betAveen flexion 
and extension of the finger. 

Operative Technique 

Taa'o incisions are made on each finger, — one placed radiall3' and 
one ulnarlJ^ The incision begins at about the mid-part of the second 
phalanx, and runs obliquelj^ and proximallj'' in the line of the collateral e.x- 
tensor tendon to about the mid-part of the first phalanx. Each collateral 
tendon is identified, soA'cred transA'erselj^ distallj’’, and stripped proximallj*. 
The entire tendinous band is removed at the mid-part of the first phalanx, 
beloAV the proximal interphalangeal joint. False dissection must be 
avoided. The thin central fascial extension OA’cr the second phalanx is 
untouched, and it is through its action that extension is hoped for. The 
common extensor tendon is sectioned transA-er.^ch' at the level of the 


A'OL. XX. XO. 1. J.\Nr.\UA’ 1P3S 



142 


M. S. BURMAN 



Fig. 4-A 



Fig- 4-B 


Case E. F., a girl of fourteen, with a 
left hemiplegia. The extreme intrinsic 
hyperextension of the fingers is shown 
above. The thumb is kept out of the 
palm after a thenar stripping as shown 
below. 


Case E. F. The photograph below 
shows the opened hand, with the wTist 
held passively in dorsiflexion; that above 
shows the peculiar flexion position of the 
terminal phalanx of the index finger 
after incomplete division of its e.xtensors. 
The thumb is out of the palm, but 
its terminal phalanx is in hyperex- 
tension following a lengthening of 
the flexor pollicis longus. 

proximal interphalangeal joint. 
It slips back about three- 
eighths of an inch, but further 
retraction is not allowed, since 
it is held in the extensor apo- 
neurosis. The wound is closed, 
and the finger is bandaged in 
flexion. 


Illusiraitve Case 



-■-*1 


Fig. 4-C 


CaseE. F. The appearance of the index finger The left hand of E. F., a girl 

after reoperation upon the extensors. fourteen years old, showed an c.x- 

treme intrinsic spastic hyperexten- 
sion deformity of the fingers and spastic indrawing of the thumb into the palm with 
terminal-phalanx flexion. (See Figure 4-A.) On April 24, 1935, a thenar stripping was 


THE JOURNAL OF BONE AND JOINT SURGERY 


THE SPASTIC HAND 


143 


done under local anaesthesia. On August 21, 1935, the flexor pollicis longus was length- 
ened, and the collateral extensor tendons of the index and middle fingers were stripped. 
(See Figure 4-B.) It was necessar 5 ' to reoperate on the index finger, since h 3 TDerextension 
of the proximal interphalangeal joint was still present. This was done on April 1, 1936, 
and the common extensor tendon was cut transversely at the level of the proximal inter- 
phalangeal joint. (See Figure 4-C.) 

The patient was last examined in September 1937. The thumb was kept out of the 
palm. The terminal phalanx of the thumb was usualfy in some hyperextension. A mild 
valgus deviation of the thumb (pollex valgus) was noted, with protmsion of the head of 
the first metacarpal radiallj’. This was due to opening of the lateral joint capsule and to 
the bowstring action of the medially displaced long extensor tendon. The index and 
middle fingers were flexed, especially by the action of the flexor sublimis. A certain 
amount of extension of the fingers was allowed, so that the patient used the hand better as 
a support when eating or doing ordinary work. 

SPASTIC FLEXION-ABDUCTION POSITION OF THE FINGERS 

Spastic flexion-abduction position of the fingers is maintained by a 
spasticity of the interossei dorsales in exeess of the interossei volares. 
The author has not 
seen spastie eontrac- 
ture in flexion-adduc- 
tion of the fingers. 

Illustrative Case 

F. B., male, thirty- 
seven years of age, has a 
residual disability of the 
left hand following a sud- 
den stroke on December 
27, 1934. This disability 
is a spastic intrinsic flex- 
ion-abduction position of 
the fourth and fifth fin- 
gers. (See Figures 5-A 
and 5-B.) The fingers 
are flexed at the metacar- 
pophalangeal joints and 
extended at the proximal 
interphalangeal joints. 

They are also abducted 
and cannot be adducted 
in the intrinsic position. 

The middle finger is in 
neutral position, and the 
index finger is held in ex- 
tension at the metacarpo- 
phalangeal joint and in 
slight flexion at the inter- 
phalangeal joints. The 
patient has a fair amount Fig. 5-B 

of strength in the hand. Case F. B., male, thirty-seven years of age, showing the 
but the grip cannot be spastic flexion-abduction'position of the fingers. 

VOL. XX. XO. JAXUAUY 1938 






144 


M. S. BURMAN 


maintained. He can pick up verticall}’^ placed objects only by cupping his 
hand. 

The disability of his hand is due to a spastic imbalance of the intrinsic muscles of the 
hand in favor of the interossei dorsales. Most of the spasticity is confined to the distribu- 
tion of the motor branch of the ulnar nerve. This nerve was injected with novocain, the 
injection being made between the pisiform and hamate bones, with resultant ulnar-nerve 
hypaesthesia and a feeling of looseness in the affected fingers. The reverse deformity was 
not produced. The stripping of the affected interossei dorsales has been recommended. 

SPASTIC ANTERIOR SUBLUXATION OP THE HEAD OF THE FIRST METACARPAL 

BONE 

This is a not uncommon subluxation of the spastic thumb and is due 
usually to overpull of the long and short extensors of the thumb, so that, 
by a bowstring action, the head of the first metacarpal is forced forward. 
It may be due in some cases to pull of the flexor pollicis brevis, but this is 
less usual as an etiological factor. It is not surprising that such a sub- 
luxation may develop, since it may be present in the normal hand as a 
trick motion by extensor action in loose-jointed individuals. Karely, it 
may exist as a fixed deformity. It is ordinarily not an isolated phenome- 
non in spastic paralysis and is almost always associated with thenar-mus- 
cle spasm. It may develoji after operation in a patient in whom it has not 
existed before. In a spastic mobile hand, it will surely come on after 
lengthening of the flexor pollicis longus. The balance of power then 
swings over to the extensor side of the thumb. It may develop in a non- 
mobile spastic hand after stripping of the thenar muscles, if the meta- 
carpophalangeal joint has been opened and the thumb immobilized in 
slight extension. Therefore, after these procedures care should be taken 
to put pressure dorsally upon the head of the first metacarpal, either by 
splint or by plaster. 

COMMENT 

In this consideration of the spastic hand from a kinesiological view- 
point, especial emphasis has been placed on those constant elements in 
spastic position which are conditioned by spasticity of the intrinsic 
muscles. The extrinsic spastic hand has not been considered, since the 
author has observed only one case of extrinsic hyperextension deformity 
of the fingers. 

The operative procedures described for the correction of spastic op- 
position position or contracture of the thumb, spastic adduction position 
of the thumb, and marked intrinsic hyperextension of the fingers are not 
intended to be complete in themselves as a form of therapy. They are 
only aids in the treatment of a hand whose spasticity should be relieved by 
curare and whose education should be lifelong. 


REFERENCES 

Biesalski, K., ttnd Mayer, L.: Die plij-sloiogische Sehnenveipflanzung. Berlin, 
Julius Springer, 1916. 

Brockway, AL^^A: The Problem of the Spastic Child. With Clinical Summary of 
One Thousand Cases. J. Am. Med. Assn., CVI, 1635, 1936. 


THE JOURNAL OF BONE AND JOINT SURGERA 



SPASTIC INTRINSIC-MUSCLE IMBALANCE OF THE FOOT 


145 


Dowd, C. N. : Tendon Transfer for the Correction of Spastic Hand Deformity. Med. 
Record, LXXVIII, 175, 1910. 

Foerster, O. : Die Therapie der Motilitatsstorungen bei den Erkrankungen des Zentral- 
nervensj'stems. In Vogt’s Handbuch der Therapie der Nervenkrankheiten. 2. Bd., 
S. 860, 893, 894. Jena, Gustav Fischer, 1916. 

Gill, A. B. : Stoffel’s Operation for Spastic Paralysis, with Report of Thirty-Two Cases. 
Am. J. Orthop. Surg., Ill, 52, Feb. 1921. 

Hey.man, C. H. : Stoffel Operation for Spastic Paralysis. With Report of Twenty-Four 
Cases. Surg. Gynec. Obstet., XXXVI, 613, 1923. 

SiLFVERSKioLD, NiLs: Orthopiidische Studie iiber Hemiplegia spastica infantilis. Acta 
Chir. Scandinavica, Supplementum V, 1924. 

Steindler, a.; The Pill Roller Hand Deformities Due to Imbalance of the Intrinsic 
Muscles. Relief by Ulnar Resection. J. Bone and Joint Surg., X, 550, July 1928. 

The Mechanics of Muscular Contractures in Wrist and Fingers. J. 
Bone and Joint Surg., XIV, 1, Jan. 1932. 

Stoffel, Adolf; The Treatment of Spastic Contractures. Am. J. Orthop. Surg., X, 611, 
May 1913. 

VuLPiiJS, Oskar, und Stoffel, A. : Orthopiidische Operationslehre. 2. Aufl., S. 63, 78, 
716. Stuttgart, Ferdinand Enke, 1920. 


SPASTIC INTRINSIC-MUSCLE IMBALANCE OF THE FOOT 

Resection of the Motor Branch of the Lateral Plantar Nerve 
FOR Intrinsic-Muscle Contracture 

BY MICHAEL S. BURMAN, M.D., NEW YORK, N. Y. 

From ihe Hospital for Joint Diseases * 

Spasticity of the intrinsic muscles of the foot results in fle.xion of the 
toes at the metatarsophalangeal joints and extension or hyperextension 
at the interphalangeal joints. There may be fixed contracture or mutable 
position of the toes. The great toe is flexed at its metatarsophalangeal 
joint by pull of the flexor hallucis brevis and extended at the interpha- 
langeal joint. 

This deformity of the foot corresponds to the more common spastic 
intrinsic-muscle deformity of the hand. In the hand, it is the motor 
branch of the ulnar nerve which innervates the intrinsic muscles; in the 
foot, it is the motor branch of the lateral plantar nerve by which these 
muscles are innervated. This nerve supplies all the interossei except 
those in the fourth intermetatarsal space, which have their own little twig 
from the proper digital nerve of the superficial branch of the lateral 
plantar nerve. The first interosseous dorsalis muscle often receives a twig 
from the medial branch of the deep peroneal nerve; the second interos- 
seous dorsalis muscle, from the lateral branch of the same nerve. The 
second, third, and fourth lumbricalcs and the adductor hallucis arc also 
* Service of I..eo Mayer, M.D. 


VOL. XX, X'O. 1. JAXUARY IflSS 



146 


M. S. BURMAN 


supplied by the motor branch. The first lumbricalis and the flexor 
hallucis brevis are innervated by branches from the medial plantar 
nerve. 

Sometimes the action of the intrinsic and extrinsic muscles is not 
coordinated, so that one or more of the toes may be in the intrinsic posi- 
tion and the others in the extrinsic position. This is found in mobile 
spastics, especially in dystonics. 

It is the poor jaivotal support of the toes which makes walking and 
standing difficult that makes necessary some form of operation in fixed 
intrinsic contractvu’e of the foot. Resection of the motor branch of the 
lateral plantar nerve, plus plantar capsulotomy of the metatarsophalan- 
geal joint of the great toe and section of the heads of insertion of the 
flexor hallucis brevis, is the operation of choice. Resection of part of the 
posterior tibial nerve at the level of the internal malleolus is also to be 
considered. 

The development of the contracture is theoretically hindered by an 
equinus position of the foot, which creates a passive insufficiency of the 
dorsiflexors of the foot. 

TECHNIQUE OF THE OPERATION 

The bony landmark is the styloid tuberosity of the fifth metatarsal 
bone. A four-inch longitudinal incision, which begins about three- 
quarters of an inch proximal to the styloid tuberosity, is made on the sole 



Fig. 1-A Fig. 1-B 

H. K., before operation. The toes are sharply flexed at the metatarsophalangeal 
joints and hyperextended at the interphalangeal joints. An equinus deformity ot 
the foot is present. 


TIIK JOURXAL OK HON'K AND JOINT SKGUKRV 



SPASTIC INTRINSIC-MUSCLE IMBALANCE OF THE FOOT 


147 


of the foot in the groove which indicates the line of separation between 
the central and lateral compartments of the sole of the foot. The lateral 
plantar nerve runs obliquely, distally, and laterally in the proximal part 
of the wound, a little proximal to the line of the styloid tuberosity of the 
fifth metatarsal. The nerve lies beneath the plantar fascia, between the 
flexor digitorum brevis and the quadratus plantae muscles. These mus- 
cles need not be isolated. The tendency is to cut too deeply, whereby 
both nerve and vessels may be severed at their point of proximal bending. 
The lateral plantar artery lies just proximal to the nerve at the point of 
bending of the nerve. Distal to this bend, the nerve runs in the space 
between the central and lateral compartments. The nerve is dissected 


out and the motor branch and the twig to the 
fourth interosseous space are isolated. The motor 
branch is placed dorsomedially on the common 
trunk of the nerve before its division. The twig 
to the fourth interosseous space arises from the 
proper digital branch to the fifth toe. The 
branches, once identified, are cut, and the wound 
is closed in layers. 

The plantar aspect of the metatarsophalan- 
geal joint of the great toe is approached by a 
medial longitudinal incision. Both heads of the 
flexor hallucis brevis are cut, and the plantar cap- 
sule is opened. An incision in the plantar crease of 
the great toe is made distal to the metatarsophalan- 
geal joint. In the following case, this approach 
was not used, and a longitudinal incision over the 
ball of the toe was made. This is not a satisfac- 
tory inci.sion. 


CASE REPORT 

H. K., male, aged thirty-five, was admitted on March 
3, 1936, for the correction of multiple deformities due to 
spastic paraplegia. The deformities of the right hip and 
knee were corrected. The results of these operations were 
good. Accurately fitting braces were applied, but walking 
with braces and crutches was very difficult because of lack 
of training and a deformit}' of the toes of the right foot 
which gave no pivotal support to the foot. The toes were 
flexed sharply at the metatarsophalangeal joints and liyper- 
extended at the interphalangeal joints, in fixed contracture. 
Tlic terminal phalanx of the fifth toe was flexed rather than 
extended, probably bj' shoe pressure. The great toe was 
flexed at the metatarsophalangeal joint and extended at 
the interphalangeal joint in fLxed deformity. .An equinus 
deformity of the right foot was present. There was no 
active muscle power in the right foot. The toes of the left 
foot were in a fairlj’ neutral position. 

On April .5, 1930, five cubic centimeters of ‘2-per-cent.- 



Fig. 2 

H. K., after operation. 
This picture was taken 
before the patient’s dis- 
charge from the hospital 
in the early part of Octo- 
ber 1936, showing the ap- 
pearance of the toes after 
resection of the motor 
branch of the lateral 
plantar nen'e and the 
twig to the fourth interos- 
seous space. A plantar 
capsulotomx' of the meta- 
tarsophalangeal joint of 
the great toe was also 
done, together witli sec- 
tion of the heads of the 
flexor hallucis brevis. 
This improvement has 
persisted and was so 
noted at the patient’s last 
examination on October 
17, 1937, fourteen months 
after operation. The ap- 
pearance of the toes now 
is as seen in this picture. 


VOI., X.X. NO. 1. JANTAnY ISIS 




148 


M. S. BUllMAN 


novocain solution was injected into the sole of the right foot in tlie region of the motor 
branch of the lateral plantar nerve. Ilypaesthesia of the fourtli and fifth toes followed. 
The hyperextension of the fourth and fifth toes gave way to a more neutral position of 
the toes; that of the second and third toes was not so markedly diminished. There 
was no hyperextension at the metatarsophalangeal joints, and the exact amount of flexion 
at these joints was hard to determine because of oedema of the dorsum of the foot, 
following capsulotomy of the knee joint. The toes could be manually flexed, a move- 
ment not previously allowed. 

On August 25, 1936, resection of the motor branch of the riglit lateral plantar nerve 
and the operative procedure on the right great toe were done. The twig to the fourth 
interosseous space was isolated and cut. Electrical stimulation of the nerves before 
resection gave no movement of the toes. The wounds healed normally. On September 
11, 1936, manipulation of the right foot was done. The toes were brought into neutral 
position after each joint of the toes had been separately manipulated. Many adhesions 
were heat’d snapping. It was difficult to coi’rcct the flexion contracture of the second 
and third toes at the metatarsophalangeal joints. The great toe was also manipulated. 
The foot was brought into 85 degrees of dorsiflexion. Tlie left foot needed no operative 
procedure. 

The patient was then transferred to a city hospital and later to a convalescent home 
in Connecticut where he was last seen on October 17, 1937. The follow-up period of 
about fourteen months is a sufficient lengtli of time to estimate the end result. 

In view of the joint contractnre.s, it was not expected that a complete 
reversal of position could take place, and this was indicated by the test of 
novocain injection. The operative procedure could not interrupt the 
nerve supply to the first lumbricalis or to the flexor hallucis brevis, nor 
could it affect the deep peroneal supply of the first and second interossei 
dorsales. It took a certain length of time for the alteration of position of 
the toes to be brought about in the presence of fixed contracture of the 
toes. It reached its maximum after manipulation of the toes, Avhich 
loosened up the joints enough for moderate reversal of position. 

The right foot is still held in equinus of 120 degrees. The scars on the 
sole of the foot healed normally and are not painful on weight-bearing. 
The position of the toes is greatly improved. The fourth and fifth toes 
show slight flexion of the interphalangeal joints and neutral position at the 
metatarsophalangeal joints. The second and third toes are still slightly 
extended at the interphalangeal joints and slightly flexed at the metatarso- 
phalangeal joints. The toes are still stiff and somewhat tender on manip- 
ulation. A limited amount of motion, not exceeding 5 to 10 degrees, 
is allowed. The great toe shows better position. There is flexion at the 
metatarsophalangeal joint of 165 to 170 degrees, and the interphalangeal 
joint is in 185 degrees of extension. The patient can walk with braces 
and crutches for at least half a block. The correction of the equinus 
deformity of the foot, proper adjustment of the braces, and training in 
crutch walking should increase his ability to walk. 


Tin-: JOURX.-VL of bone and joint surgery 



THE ROLE of the DISCUS ARTICULARIS IN 
COLLES’ FRACTURE 

BY GRANTLEY W. TAYLOR, M.D., F.A.C.S., AND C. LANGDON PARSONS, M.D., 
F.A.C.S., BOSTON, MASSACHUSETTS 

Froyn the Surgical Service of the Massachusetts General Hospital 
ANATOMY 

The fiLinctiou of pronatioii and supination of the forearm is of enor- 
mous importance, and its loss or impairment causes gra^•e disability. The 
ulna plays a purely passive role in this motion, serving as a fixed point 
about which the radius moves. The proximal and distal radio-ulnar 
joints which are concerned not only must permit the full range of motion, 
but also must maintain the bones in secure apposition throughout this range. 
Proximally this purpose is served by the cylindrical end of the radius 
securely held to the ulna Ijy the annular ligament which is attached to the 
anterior and posterior margins of the lesser sigmoid articular concavity. 
At the distal end, the roughly quadrilateral radius presents on its mesial 
aspect a smooth con- 
cave surface for artic- 
ulation with the ulna. 

The ulna presents a 
cylindrical articular 
surface for about two- 
thirds of its circum- 
ference (Fig. 1). This 
articulates smoothl 3 '- 
with the lower end of 
the radius throughout 
the full range of its 
motion. The security 
of this joint is assured by the discus articularis, or triangular ligament. 
This structure lies between the head of the ulna and the pro.ximal row of 
the carpus as a thick, fan-shaped, fibrocartilaginous plate, attaclied bj’' its 
apex to the depres.sion at the base of the ulnar stjdoid. From this point 
the fibers fan out to become attached to the curved sigmoid edge of the 
radius. It should be noted that tlie sigmoid surface forms an arc facing 
mediallj^ and that the motion of the radius about the ulna follow.? the 
prolongation of this arc. The locus of points equidistant from this arc — 
namelj’^, the center of the circle of which the arc forms a part — is repre- 
sented bj' the jjoint of attachment of the discus articularis to the ulna 
(Fig. 1). Thus in the normal wrist this ligament remains tense in anj- 
position of the joint. Other ligaments, notablj' the capsular ligaments 
and the ligaments of the wrist joint itself, undoubtedly' strengthen the 

I-IO 



Fig. 1 


Distal end of ulna and radius in pronation (left) and 
supination (right). Note the arc of motion of the radius 
about the ulnar head. Tlic point of attachment of the 
discus articularis (x) is at the center of the circle of which 
the arc forms a part. From this point the fibers of the 
ligament fan out radially to attach to the edge of the 
sigmoid cavity, as shown by the dotted lines. 


voi.. xx. xo. 1. JAXU.^UY less 



150 


Cx. W. TAYLOR AND C. L. PARSONS 


joint at various points of its motion, notably at the extremes, although 
obviously they must be lax enough to permit the full range of motion to 
take place. The discus articularis is unique in stabilizing the joint in any 
position whatsoever. The distal surface of the vdna is covered with 
articular cartilage to irermit the ligament to glide over it. The carpal 
surface of the ligament prolongs the articular surface of the distal end of 
the radius for articulation with the proximal row of the carpus in the 
wrist joint. 

COLLEs’ FRACTURE 

It is probable that the discus articularis suffers some damage in any 
injury severe enough to result in a fracture of the distal end of the radius. 
In most instances, the degree of injury to the ligament does not destroy its 
function of maintaining the integrity of the radio-ulnar joint. In certain 
more severe fractures, the ligament may be ruptured, or avulsed from its 

attachment to the radius or ulna, with or without a 
fragment of bone (Fig. 2). It is our contention 
that the successful management of Colles’ fracture 
is in large part dependent on the integrity of the 
radio-ulnar joint, which in turn depends upon an 
intact' discus articularis. In considering treatment, 
we find it helpful to divide our group of Codes’ 
fractures into two main classifications; 

1. Fractures with the discus articularis intact. 

2. Fractures with loss of integrity of the radio- 
ulnar joint, due to: 

a. Rupture of the ligament itself. 

b. Avulsion of the ulnar styloid at its 
base. 

c. Severe comminution of the lower end 
of the radius with the ligament at- 
tached to a loose minor medial 
fragment. 

In the first group, despite displacement, com- 
minution, and impaction, the problem is a relatively 
simple one. The intact radio-ulnar joint serves as a fixed point around 
which to reconstruct the normal anatomy. In the second group, the 
distal fragment moves with the carpal bones as one unit, A\diile both bones 
of the forearm move as another unit and with little relation to each other. 

A proper reduction and fixation under such conditions becomes a com- 
plicated problem for there is no fixed point around which to build either 
the reduction or the fixation. It is with this second group of cases that 
we are here concerned. While recognition of the complicating injury 
may be difficult, proper treatment of the fracture depends upon dis- 
tinguishing these cases. 



Anteropostei'ior view 
of both bones at the 
wrist, showing the at- 
tachments of the discus 
articularis. Note that, 
fractures occurring 
through the base of the 
ulnar styloid or through 
the medial aspect of the 
radius pei-mit loss of 
integrity of the radio- 
ulnar joint. This may 
also occur through rup- 
ture or avulsion of the 
ligament without an 
attached bone frag- 


THE JOURNAL OF BONE AND JOINT SURGERY 



THE DISCUS ARTICULARIS IN COLLES FRACTURE 


151 


DIAGNOSIS 

The typical deformity of Colies’ fracture involves some degree of 
supination of the distal radial fragment in relation to the shaft of the bone. 
This in itself is responsible for the loss of the dorsal prominence of the ulna 
which is present in the normal wrist in pronation. If the integrity of the 
radio-ulnar joint has been lost, the ulnar head lies much farther forward, 
even presenting as a bulge on the volar aspect of the wrist. In addition, 
it will be found to be abnormally movable in relation to the radius and to 
the hand. It also often presents as a distinct prominence on the medial 
aspect of the wrist, where it is responsible for the abnormal broadening 
which is characteristic of the severer fractures. Marked forward or 
medial displacement of the ulnar head, combined with abnormal mobility, 
is the chief clinical evidence of a loss of the joint integrity. In addition, 
there is more pain on attempt to carry out pronation and supination than 
in the case of a simple Colles’ fracture. Roentgenographic evidence con- 
firms the separation of the ulnar head from its relation with the distal 
radial fragment, and a lateral view usually shows the marked forward 
displacement of the head. In the diagnosis of simple rupture of the liga- 
ment uncomplicated by fracture — a very rare injury — it may be necessary 
to take roentgenograms at various positions of pronation and supination 
to reveal the separation. Roentgenographic evidence of fracture through 
the base of the ulnar styloid, or of separation of a medial fragment of the 
radius (Fig. 2) is also confirmatory of loss of joint integrity. The impor- 
tance of recognition of this complicating injury cannot be overemphasized. 

TREATMENT 

Prompt accurate restoration of normal anatomical relationships is 
very important. We believe that reduction should be carried out under 
the fluoroscope, with general anaesthesia. Unless there is a definite con- 
tra-indication to ether, we do not advise the use of novocain in these more 
complicated cases. Special attention must be paid to breaking up the 
impaction, restoration of the proper length and articular angle of the 
radius, and restoration of the dorsal position of the ulna. 

At the same time, the ulna must be brought into close apposition to 
the radius to prevent widening of the wrist. The most stable position for 
fixation is that of pajmar flexion with extreme pronation and ulnar devia- 
tion, the so-called Cotton-Loder position. If the ulna has been properly 
restored to its dorsal position, this manoeuver wedges the hamate partly 
beneath the distal ulna, and prevents forward lu.xation. This then gives 
stability to the ulnar side of the wrist ; and further palmar flexion, prona- 
tion, and ulnar deviation put traction through the carpal ligaments on the 
radial fragments, lifting them into place and using the wedged ulna as a 
fulcrum.., Continuance of ulnar deviation serves further to snug the 
radius up to the ulna and to permit reparative proce.sscs to reconstruct the 
ligamentarj’^ attachments. Maintenance of the position is greatl3' facili- 
tated bj' immobilization of the elbow, which prevents anj- possibilit3' of 

you XX, XO. I. JAXOAnV loss 



TABLE OF CONTENTS 


I’AGK 

Treatment of Scoliosis by the Wedging Jacket and Spine Fusion. A Review 
OF 265 Cases. 

By Alan DeF. Smilh, M.D., Felix L. Butte, M.D., and Albert B. Ferquson, AT.D., 

NewYork, N. Y '. 825 

Correction of Extreme Flexion Contracture of the Knee Joint. 

By S. L. Haas, M.D., San Francisco, California .839 

Sciatic Pain of Unknown Origin. An Effective Method of Treat.ment. 

By G. E. Haggart, M.D., Boston, Massacliusctts 851 

The Scalenus Anterior Muscle in Relation to Shoulder and Arm Pain. 

By Joseph A. Freiberg, M.D., Cincinnati, Ohio 800 

Giant-Cell Tumor of Bone. 

By Bradley L. Coley, M.D., and Norman L. Iliginbotham, M.D., Now York, 

N. Y 870 

The Mechanics of the Formation of the “Secondary Acetabulu.m” in Con- 
genital Dislocation of the Hip. 

By Aladdr Farkas, M.D., Budapest, Hungary 885 

Primary Hemangioma Involving Bones of the Extremities. 

By Charles F. Geschickter, M.D., and I. H. Maseritz, M.D., Baltimore, Mary- 
land 888 

Bone Block for Painful Hips. 

By J. B. L’Episcopo, M.D., Brooklyn, New York 901 

The Healing of Joint Fractures. A Clinical and Experimental Study. 

By Keene 0. Haldeman, M.D., San Francisco, California 912 

An Operative Technicjue for Hallux Valgus. 

By Max A. Levine, M.D., Los Angeles, California 923 

Recurrent Anterior Dislocation of the Shoulder. Report of Eleven 
Cases Operated on by the Method of Roberts. 

By Burgh S. Burnet, M.D., Hot Springs National Park, Arkansas 926 

The Results of Treatment of Osteogenic Sarcoma. 

By Henry IF. Meyerding, M.D., Rochester, Minnesota 933 

Roentgenotherapy in Acute Osteoporosis. A New Type of Treatment. 

By E. B. Mumford, M.D., Indianapolis, Indiana 949 

A Review of the Campaign for the Establishment of Surgical Principles 
IN THE Treatment of Fracture of the Neck of the Femur. 

By Royal Whitman, AI.D., New York, N. Y 960 

A Clinical and Anatomical Study of the Semimembr.ynosus Bursa in Rel.\- 
tion to Popliteal Cyst. 

By P. D. Wilson, M.D., A. L. Eyre-Brook, F.R.C.S., and J. D. Francis, M.D., 

New York, N. Y 963 

Gas-Bacillus Infection as a Complic.^tion of Fractures. 

By David M. Bosworth, M.D., New York, N. Y 98 .j 

Backache. A Manipul.a.tive Tre.vt.ment without Anae-sthesia. 

Bj' Frederick A. Joslcs, M.D., St. Louis, Missouri 990 


{Continued on page 15 following Current Literature) 



OSSIFICATION OF THE TENDO ACHILLIS 

BY JOHN TV. GHORJILEY, M.D., ALBANY, NEW YORK 
From the Department of Surgery, Albany Medical College 

Ossification of the tendo achillis is a definite, yet rare, clinical entity. 
Usually the ossification results from heterotopic bone formation arising 
within the bod}’- of the tendon; sometimes it develops from the periosteum 
of the os calcis. As far as the writer has been able to determine, only 
twenty-one cases have been reported in the literature. The various au- 
thors offer man}'- possible explanations of this phenomenon. It is sug- 
gested that the ossification may be: (1) an embryonic rest or inborn 
anomaly; (2) a neoplastic growth; (3) a sesamoid bone such as is found in 
the tendons of birds; (4) osteogenesis from osteoblasts circulating in the 
blood stream; (5) growth of bone from a torn or injured periosteum; (6) 
chronic infection; (7) trophic disturbance due to tabes dorsalis; (8) bone 
formation by fibroblasts which have taken over a bone-forming function; 
(9) bone formation by osteoblasts which have metamorphosed from 
fibroblasts. 

Sixteen of the twenty-one patients whose cases have been reported 
were males and five were females. In eighteen cases the new bone ap- 
parently developed free in the body of the tendon. In three it was 
thought to have been an outgrowth from the calcaneum. Seven patients 
gave a history of definite injury, such as a blow on the heel or a sprain of 
the tendon. Five gave a history of club-foot; four of these patients had 
had a tenotomy of the Achilles tendon and one a resection of the plantar 
fascia. Two cases were attributed to injury to the periosteum of the cal- 
caneum at the point of the insertion of the tendon, due in one case to the 
wearing of high-heeled shoes and in the other to stiff counters on the shoes. 
In one case syphilis was blamed; in another, tabes dorsalis. In one case 
there had been an old osteomyelitis of the calcaneum; and in another, an 
abscess of the gastrocnemius. In three cases no apparent cause e.xisted. 
In only one of the reported cases was there a rupture of the tendon. 

When the ossification is due to outgrowths from the calcaneum, it is 
analogous to traumatic myositis ossificans and may be termed “tendonitis 
ossificans traumatica”. A great deal of experimental work has been done 
and many clinical observations have been made in an effort to explain 
heterotopic bone formation, but there is no agreement as to the exact 
mechanism of this phenomenon. Leriche feels that it is a simple process 
and states that it originates with an injur}’ or tear in the tendon. Hemor- 
rhage follows, and later calcification of this necrotic area results. Tliis 
calcification stimulates the fibroblasts to form bone. Huggins demon- 
strated that the epithelium of the urinary bladder stimulates certain 
fibroblasts to form bone. He does not believe that intermediate calcifica- 


VOI., XX. XO. 1. JAXUAnV 1P3S 


15:5 



152 


G. W. TAYLOR AND C. L. PARSONS 


supination. Acute palmar flexion alone, without pronation and ulnar 
deviation, will not suffice to maintain reduction in many instances, for 
slipping of fragments may occur. Fixation in the desired position is 
secured by a plaster-of-Paris cylinder or preferably by the so-called sugar- 
tong splint made of a single strip of plaster. 

This extreme position of reduction should not be maintained for 
more than ten days, after which the wrist should be restored to a neutral 
position and safeguarded with simple molded splints for another ten days. 

After-care and physiotherapy are carried out in this type of fracture 
essentially as they are in the less complicated type. Disability usually 
lasts for about two months. 


LATE CASES 


A considerable number of cases of Colles’ fracture are treated without 
recognition of this complicating factor of loss of integrity of the radio-ulnar 
joint. These cases account for most of the poor end results seen after this 
fracture. Shortening of the radius and the backward tilt of its carpal 
articular surface are usually due to failure to break up the impaction com- 
pletely. The broad wrist and loss of the dorsal prominence of the ulnar 
head are due to failure to restore the ulna to its proper position in the re- 
duction. Limitation of motion occurs chiefly in pronation and supina- 
tion, and this motion is likely to be painful and is sometimes accompanied 
with a jog or even an audible click. There is usually tenderness over the 
ulnar head or the ulnar collateral carpal ligaments, and the patient is 
likely to refer pain to these areas. In the extreme cases the ulnar head 
presents marked abnormal mobility, in some positions appearing as a 
dorsal prominence and again medially or anteriorly. If the ulnar head is 
grasped, it can be found to be freely movable in relation to the radius and 
to the hand. 

In some instances simple osteotomy to restore the radius to its 
proper position is sufficient to relieve the patient of his disabling symp- 
toms h More often and more effectively, subperiosteal resection of the 
distal end of the ulna is employed as described by Darrach, and Cotton 
and Morrison. 

SUMMARY 


The function of the discus articularis is to stabilize the inferior 
radio-ulnar joint. 

This ligament may be injured in Colles’ fracture. 

This complication requires a different technique of reduction and 
immobilization. 

Failure to recognize the injury definitely jeopardizes a favorable 


prognosis. 


REFERENCES 


1. Cotton, F. J.: Personal communication. 

2. Cotton, F. J., and Morhison, G. M.: Resection of the Lower End of the Ulna (Sub- 
periosteal). New England J. Med., CCXI, 1/0, 1934. 

3. Darr-^ch, William: Anterior Dislocation of the Head of the Ulna. Ann. Surg., 
LVI, 802, 1912. 


THE JOURNAL OF BONE AND JOINT SUROERV 



OSSIFICATION OF THE TENDO ACHILLIS 


155 


the rather strenuous du- 
ties of a railroad trainman. 

He complained some of 
pain in the heel for about 
a year after the operation. 

At that time the repair 
seemed strong and the 
lift on the heel was dis- 
carded. Examination in 
November 1936 revealed 
slight tenderness and in- 
duration about the region 
of the tendon, but there 
was no e^ddence of weak- 
ness, or of impaired func- 
tion, or of defect in the 
tendon. 

This case is un- 
doubtedly one of het- 
erotopic bone forma- 
tion of the tendo 
achillis. The cause 
of that ossification is 
uncertain. Possibly 
the patient may have 
torn the fibers of the 
tendo achillis eleven 
years preidously when 
he fractured the right 
os calcis, although 
there is no history of 
.such an injury. The 
fact that he has a de- 
ficiency of the neural 
arch of the first sacral 
segment makes one 
consider that the ossification in the Achilles tendon may be an associated 
congenital phenomenon. 

abstracts of reported cases 

Horing. The patient was a man, fifty-si.x years old, roentgenographic 
examination of whom showed evidence of two shadows in the left Achilles 
tendon. This was thought to have been caused by the patient's striking 
the heel on a hard object almost a year previously, as he had had pain in 
that heel almost constantly since that time. There was some bone for- 
mation in the right Achilles tendon, although there had been no injury' 
there. The mass removed from the left Achilles tendon sliowed some 
cartilage and some spongy bone. Horing termed this condition ‘‘tendon- 

VOL. XX. XO. 1. JANUARY 1938 





154 


J. W. GHORMLEY 


tion is necessary; he also differs with Leriche in that he feels that an osteo- 
blast is a specific type of cell. Jones and Roberts state that the osteoblast 
is simply a fibroblast enlarged because it is active, and that bone will be 
formed at any point where there is excess calcium, provided that there is 
an adequate blood supply. It is obvious, then, that the exact mechanism 
of this ossification is not clear. 

Treatment of this condition is not difficult. If no symptoms are 
present, no operative procedure is necessary. If pain is found, operative 
removal of the ossification is desirable. In cases of rupture of the tendon, 
suture of the tendon is necessary Avith or without remoA’-al of the ossified 
area. 


CASE REPORT 

N. M., white male, aged forty-two years, a railroad trainman, had been in the hos- 
pital on two occasions previous to the present accident. He had been hospitalized for 
two days in 1922 for treatment of an urethral stricture which was thought not to be 
gonorrhoeal. Routine roentgenograms of the kidneys were negative, but a deficiencA'^ of 
the neural arch of the first sacral segment was noted. Several months later the patient 
had been in the hospital again because of a fracture of the right os calcis. He had fallen 
from the top of a slowly moving boxcar and had landed on the tracks twelve feet below. 
There was little or no displacement of the fragments, and a cast was applied without 
anaesthesia. At that time there was no complaint of injury to the left foot or ankle. 
The patient had returned to work after four months entirely well. 

On August 15, 1933, the patient was at his work, running along a stone-ballasted 
track to throw a switch, when he felt something snap in the left heel. He had not turned 
the ankle and was at a loss to explain the cause of his trouble. He did not fall and was 
able to continue on his way, but he could not rise on the toes of this foot. He was seen 
by the writer within a few hours, and inspection of the left ankle revealed moderate 
swelling and a definitely perceptible break in the continuity of the tendo achillis about 
two inches above its attachment to the calcaneum. Palpation revealed considerable 
tenderness in this area, and a forefinger placed across the back of the heel fitted deeply 
into the defect. 

Roentgenographic examination of the left foot (Fig. 1) revealed an area of ossifica- 
tion in the region of the tendon, about three inches long and three-fourths of an inch in 
diameter, the lower end of the ossified area being three inches above the insertion of the 
tendon into the calcaneum. Roentgenogi’ams of the tendo achillis of the right foot 
showed no ossification. Fourteen hours after the accident, an open operation was per- 
formed. There was a marked subacute inflammatory reaction in the tendon and the 
tendon sheath, the two being generally adherent but separable by blunt dissection. The 
tendon was separated for a distance of about one-half an inch at a point approximately 
two inches above the calcaneum. Palpation of the tendon above the point of separation 
and in the area of opacity, as demonstrated by the roentgenogram, revealed an in- 
durated bony mass. It was impossible to penetrate into it with a suture needle. The 
break in the tendon had occurred about one-half an inch below the ossified section. For 
some distance on either side of the break the tendon was very necrotic and friable, and 
histological examination of a section removed showed necrotic tendon tissue with con- 
siderable hemorrhage and a slight acute inflammatory reaction. The defect was sutured 
with kangaroo tendon, and the wound was closed with catgut. A plaster cast was ap- 
plied with the foot in the plantar-flexed position, and ten days later the patient left the 
hospital on crutches. The cast was removed after seven weeks, and the patient began to 
get about without crutches, but with a three-fourths-inch lift on the heel of the left 
shoe. He returned to his regular work after four months and has remained there, doing 

THE JOURNAI. OF DONE AND JOINT SUnOERY 



OSSIFICATION OF THE TENDO ACHILLIS 


157 


where in the bodJ^ Since the patient was having little or no trouble with 
the heel, no operation was performed. Haglund stated that, since tendon 
tissue is phylogenetically the same as muscle tissue, ossification may 
develop there as easily as it can in muscles. 

Pinard, Vernier, and Abricosof. Their patient had a large osteophyte 
in the left Achilles tendon. He also exhibited a partial positive Wasser- 
mann reaction, and the authors felt that the ossification in the Achilles 
tendon was associated ivith the syphilis. 

Koehnlein. The patient was a man of fifty-five years, who, at some 
earlier time, had had osteomyelitis of the right calcaneum. Two areas 
of bone formation were present in the Achilles tendon, — one, three and 
four-tenths by one and four-tenths centimeters, beginning at the cal- 
caneum; and another above this, two and two-tenths centimeters by six- 
tenths of a centimeter. This author discusses in some detail the possible 
causes of this condition, mentioning especially tumor, periosteal out- 
growth, inborn anomaly, and aperiosteal metaplasia. He is inclined to 
believe that the last named is the proper explanation and states that it is 
not important whether the cells which form the bone are osteoblasts or 
fibroblasts, as they both come from the same embryonic tissue originally. 

Patel. The patient was a sixteen-year-old girl who had been seen 
six months previously because of hard swellings on both of the heels. 
They had appeared some time before without known cause. They were 
sufficiently painful to interfere with walking. The tumefactions were ad- 
herent to the upper edge of the posterior surface of the calcaneum. The 
swellings on the right were the size of a nut and on the left they were some- 
what smaller. Roentgenographic examination showed no shadows. 
These nodules were removed and were found to be bone. The author felt 
that they were not sufficiently ossified to show in the roentgenogram. He 
believed that the osteomata had developed because of traction or pressure 
at the insertion of the Achilles tendon, due to the wearing of extremely 
high-heeled shoes. He thought the periosteum had been torn or irritated. 

Berard (reported in the discussion of the case of Patel). The patient 
was a woman of thirty-eight years who had had pain in the heel for some 
two years. Examination showed a column of bone, two centimeters in 
length, arising at the posterior apophysis of the calcaneum and extending 
into the Achilles tendon. The author regarded this to be an osteoma 
caused bj’- irritation or tearing of the periosteum. He thought the hard 
counters on the shoes might have started the trouble. 

Chevalier. The patient was a woman, seventy-eight years old, who 
had come to the hospital because of an abscess on the top of the left foot. 
Examination showed a painless indurated mass in the left tendo achillis. 
and roentgenograms revealed an ossified mass at this site, three or four 
centimeters long. Since this condition did not trouble the patient, no 
operation was eonsidcred. The author felt that this was some sort of 
trophic disturbance and that it was not due to periosteal injury. 

Satiiiou and Peron. The patient was sixty years old and suffered 

VOL. XX. NO. 1. JANUARY 193S 



156 


J. W. GHORMLEY 


itis ossificans traumatica” and regarded it as similar to myositis ossificans 
traumatica. 

Painter a?id Clark. The authors reported two cases. The first was 
that of a man of thirty-eight years, who had caught the left foot between 
two bales of cotton four months previously. Two nodules developed in 
the tendon soon after. The tendon Avas incised and the tAvo nodules AA'cre 
removed. Their second case Avas that of a man of fifty-one years, Avho 
had had stiffness in the cord of the right heel for five years. He regarded 
it as “rheumatism”, although there AA^as marked atrophy of the calf, 
resulting from an old inflainmatory process Avhich had destroyed the 
gastrocnemius muscle. OperatiA’'e treatment Avas not AA^arranted. These 
authors regarded the condition as similar to myositis ossificans. 

Jacohsthal. The patient Avas a man, sixty years of age, AAdio had 
bilateral congenital club-foot. Because of this condition the plantar 
fascia had been resected AAdien he Avas one year old. He had been having 
pain in the heels during the past fiAm years, this pain having come on grad- 
ually Avithout knoAvn cause. Roentgenograms shoAA’'ed a bone formation 
in the left Achilles tendon, four by nine centimeters in dimension, and one 
in the right tendon, measuring one by five centimeters. Neither mass 
was attached to the calcaneum. The author attributed the ossification 
to the tenotomy. 

Meyer. The patient Avas a man Avho had injured his foot four years 
previously. Apparently a traumatic pes equinus had developed for Avhich 
a tenotomy of the Achilles tendon had been performed. Immediately 
before he Avas seen by Meyer, he had suffered a slight injury to the heel, 
Avhich caused pain and SAA’-elling. Roentgezrograms shoAved a shadoAV 
which was regarded as either ossification or calcification, probably the 
former. The area AA'-as several inches long and Avas not attached to the 
calcaneum. Meyer thought that a hematoma had deA'^eloped in the ten- 
don at the time of the tenotomy, Avhich had become calcified and later 
ossified. 

Su7idt (cited by Mazzini, Reyes, and Monzo). This case is one of 
calcification or ossification in the tendo achillis of a boy, nine and one- 
half years old. 

Steiger. The patient Avas a Avoinan, thirty-three years old, Avhose ill- 
ness had begun AAdren she AA’-as tAA'^elve years old. A small indurated 
SAvelling dcA'^eloped on the heel. Roentgenograms demonstrated an ossi- 
fied area Avhich Avas not attached to the calcaneum It AA^as remoA^ed by 
open operation. 

Haglund. This patient Avas a man, sixty-seven years old, Avho AA'as 
seen because of disability of the left foot. He recalled that as a youth he 
had cut the heel on a scythe, but he could remember no other injury. 
Four months preAdously, acute pain and SAAnlling had developed in tlzc 
heel, AAdnch he regarded as “rheumatism”. Roentgenographic examina- 
tion demonstrated a shadoAV in the tendon. There Avas no shadoAv in the 
tendon of the other foot, nor AA'as any abnormal ossification found else- 

THE JOURNAL OF BONE AND JOINT SURGERA 



OSSIFICATION OF THE TENDO ACHILLIS 


159 


showed the ossification. No operation or microscopic studies were 
possible. This author compared this bone formation to that in tendons of 
birds. 

Jones and Roberts. The patient had had a tenotomy of the Achilles 
tendon twenty years previously. Roentgenographic examination showed 
an extensive calcification in the tendon, beginning a short distance above 
the calcaneum and extending high into the calf. There was also a cal- 
cification of the supraspinatus tendon. These authors believed that the 
ossification of the tendo achillis was one of true heterotopic bone forma- 
tion and that it followed the tenotomy. He stated that a calcareous 
deposit would naturally develop in the fibrotic area of the tendon because 
of its decreased vascularity. Ossification would follow the calcification 
in the manner described by Leriche. They stated that this is a quite 
different process from the ossification due to an avulsion of the periosteum 
of the calcaneum, the latter condition being similar to myositis ossificans. 

Mazzini, Reyes, and Monzo. These authors reported two cases. 
The first case was that of a man of seventy-six years, who had been losing 
strength in the lower extremities for the past three or four years. In ad- 
dition, he had other symptoms suggestive of a deficient circulation in the 
lower extremities. He also had some muscular rigidity, so that he walked 
on the outer borders of the feet. Examination showed marked muscle 
atrophy and coldness of both lower extremities. The roentgenogram 
showed an ossified mass, nine centimeters long, in the right Achilles tendon 
and another, eleven centimeters long, in the left Achilles tendon. The 
latter tendon had a break in the continuity as though it were fractured. 
The masses were not attached to the calcaneum. The second case was 
that of a man, forty-three years of age, who, several years previously, had 
injured the left foot while getting out of a wagon. He had caught this 
foot in a cable which was charged with electricity and he had suffered a 
severe local injury. Examination showed some discoloration of the left 
leg, as well as some oedema and venous engorgement. Roentgenograms 
disclosed an ossified area, seven centimeters long, which seemed to have 
been fractured. In addition to reporting these two cases, these authors 
summarized fifteen previously reported cases and listed the various ex- 
planations which have been offered for this ossification. 

Note: Since this article was written, another case of ossification of the Achilles ten- 
don has been reported bj’’ Hufnagl. 


SUM.MARY 

1. In some cases of o.s.sification of the tendo achillis, the os.sification 
arises from the calcaneum and is of periosteal origin. In other cases, the 
bone arises in the midst of the tendon. In spite of a great deal of experi- 
mental work and many clinical observations, the exact mechanism of this 
ossification is not clear. 

2. The possibility that in some cases this condition is due to con- 
genital defect should still be considered. Four of the case.s reported 

VOl., XX. XO. 1. J.\NC.\nY 193S 



158 


J. W. GHORMLEY 


from tabes dorsalis. Routine examination showed the swelling in the heel, 
and roentgenograms disclosed an ossification in the tendo achillis, which 
was not attached to the calcaneum. The patient had no pain in the heel, 
and no operation was performed. These authors felt that the ossifica- 
tion was a trophic disturbance and was associated with the tabes 
dorsalis. 

Mallinson. The patient was fifty-six years old and had been born 
with a bilateral talipes equinus. At eight years of age, a bilateral sub- 
cutaneous tenotomy had been performed. The patient was able to get 
about without a great deal of difficulty, but one day, while at work, he felt 
a sudden sensation in the left heel as though he had been struck a heavy 
blow. Roentgenographic examination revealed bilateral ossification of 
the tendo aehillis, with fracture of the left. Open operation was per- 
formed, and the fragments were sutured Avith sih’-er wire. Afteinvards this 
patient got about Avith a three-fourths-inch lift on the left heel. The au- 
thor mentioned the introduction of chronic infection at the time of the 
original operation as a possible cause of this condition. He also stated 
that it might liaA'^e been due to excessh'^e strain of the tendons or possibly 
to metabolic error or vitamin deficiency. 

Volkmann. The patient AA'^as a AAmman, sixty-three years old. There 
had developed on the back of the left heel AAdiat she regarded as a blister. 
She did not knoAv Avhat the cause of this Avas, but it gaA^e her considerable 
pain and made her limp. Roentgenographic examination shoAved a spur 
on the calcaneum and also tAAm ossified areas in the Achilles tendon, the 
loAver one apparently being attaehed to the calcaneum. There AA^as also 
a small bony formation at the attachment of the right Achilles tendon. 
The osseous bodies Avere removed by open operation. The author stated 
that this condition is similar to the so-called myositis ossificans and that 
it may be spontaneous, traumatic, or similar to the bony tendons found 
in birds. He regarded this case as being traumatic and due to chronic 
irritation because of painful Avalking due to the heel spurs. He believed 
that the ossification folloAved the deposition of calcium in the injured 
tendon. 

Scherb (cited by Volkmann). The patient v'^as a man, forty-nine 
years old, Avho had fractured the left femur tAventy-seven years previously. 
One year before hospital admission he had refractured the femur and had 
also fractured a metatarsal bone. Examination shoAved complete fixation 
of the subastragalar joint and a talipes equinus. The Achilles tendon Avas 
lengthened, and a small section of the bony tissue Avas remoA'^ed. Micro- 
scopic examination shoAved spongy bone as Avell as areas of calcification 
and cartilage, the central part of the body being fibrous. 

Demoio (cited by Volkmann). A man, thirty-nine years old, had 
struck the back of the left heel on a hard object thirteen years preAdously. 
An indurated sAvelling had dcA’^eloped, but it had gwen the patient little 
trouble. He came into the hospital because of an axillary adenitis; rou- 
tine e.xamination rcA'ealed the sAA'elling in the left heel and roentgenograms 

THE JOURNAL OF BONE AND JOINT SUROER'i 



TABLE OF CONTENTS 


(Continued) 


Adamaktinoma of tiik Tikia. A Repout of Two Cases. 


PAGE 


Ih’ Botjamin Wolforl, M.D., Brooklyn, New York, and David Sloane, M.D., 
AYw York, Y 


1011 


Ewing’s Titmou (Endothelial Myeloma). An Unusual Case Report with 
Necropsy. 

By (Villis C. Campbell, and J. F. Hamilton, M.D., Memphis, Tennessee 1019 


Superior Pulmonary Sulcus Tumor Simulating Subacromial Bursitis. 

By lA)uis Nathanson, M.D., and Lcio A. Hochberg, M.D., Brooklyn, New 

York, and Robert Perlman, M.D., Cincinnati, Ohio 1028 

Primary Endotheliomyeloma (Ewing’s Tumor) of the Sacrum. 

By E. A. Brao, M.D., and A. M. Rechtman, M.D., Philadelphia, Pennsylvania. 1034 


Hodgkin’s Disease of the Bones. 

By Herman S. Ldeberman, M.D., New York, N. Y 1039 

The Oper.a-Gl.ass Hand in Chronic Arthritis. “La Main bn Lougnette'’ 

OF ^ARIE AND L^RI. 

By Louis S. Helson, M.D., Brooklyn, New York 1045 

A Turnbuckle Lug for Wedging Jackets for Scoliosis. 

Bj’ Nicholas J. Giannestras, M.D., Cincinnati, Ohio 1050 

Two Rare Dislocations of the Metatarsals at Lisfranc’s Joint. 

By Edward Raymond Easton, M.D., New York, N. Y 1053 

A Wire Tightner. 

, ByPeierG. S/ii/Hn, il/.D., AnnArbor, Michigan 1057 


Acute Micrococcus Catarrhalis Arthritis. 

By Waller M. Solomon, M.D., and Henry R. Tuchewicz, B.S., Cleveland, Ohio . 1061 


Opposition of the Thujib. (Correction.) 

By Sterling Bunnell, M.D., San Francisco, California 1072 

Scoliosis in Young Infants. (Abstract of Articles by Dr. R. J. Harrenstein.) 

By Charles IF. Goff, M.D., Hartford, Connecticut 1070 

John Lincoln Porter 1064 

Edville G. Abbott 1069 

News Notes 1066 

Current Literature 1073 

Index to Volume XX 

Addresses of Contributors r 


15 



160 


J. W. GHORMLEY 


showed a congenital talipes. The case which the author has reported 
showed a congenital defect in the neural arch of the first sacral segment. 

The writer wishes to thank Miss Maude E. Nosbit and her associates at the New 
York State Medical Library for their help in connection with the bibliography. 


REFERENCES 

Chevalieh, B.: Les ost(5omes du tendon d’Achille. These de Lyon, 1931. 

Haqltjnd, P. ; Beitrag zur Klinik der Achillcssehne. Ztschr. f. orthop. Chir., XLIX, 49, 
1927. 

Horing, F. ; Ueber Tendinitis ossificans traumatica. Miinchener med. Wchnschr., LV, 
674, 1908. 

Htjfnagl, H. : Ueber die Vdrknocherung der Achillcssehne. Miinchener med. 
Wchnschr., LXXXIV, 1410, 1937. 

Huggins, C. B., McCarroll, H. R., and Blocksom, B. H., Jr. : Experiments on the 
Theory of Osteogenesis. The Influence of Local Calcium Deposits on Ossification; 
the Osteogenic Stimulus of Epithelium. Arch. Surg., XXXII, 915, 1936. 

Jacobsthal, H. : Ueber Fersenschmerzen. Ein Beitrag zur Pathologic des Calcaneus 
und der AchiUessehne. Arch. f. klin. Chir., LXXXVIII, 146, 1908-1909. 

Jones, R. Watson, and Roberts, R. E.: Calcification, Decalcification, and Ossification. 
British J. Surg., XXI, 461, 1934. 

Koehnlein, H. : Knochenbildung in Sehnen. Arch. f. klin. Chir,, CLXIII, 147, 1930. 

Leriche, R., and Policard, A.; The Normal and Pathological Physiology of Bone: Its 
Problems. Translated by Sherwood Moore and J. Albert Key. St. Louis, The 
C. V. Mosby Co., 1928. 

Mallinson, F. B. : Ossification of Both Achilles Tendons with Traumatic Fracture of One. 
British Med. J., II, 836, 1932. 

Mazzini, 0. F., Reyes, A. S., y Monzo, A.: Osificaciones en el tendon de Aquiles, 
Hueso peroneo y apofisis troclear del astragalo. Rev. de Ortop. y Traumatol., V, 
44, 1935. 

Meyer, Ludwig: Verknbcherung der Achillcssehne. Berliner klin. Wchnschr., L, 1304, 
1913. 

Painter, C. F., and Clark, J. D. : Myositis Ossificans. Am. J. Orthop. Surg., VI, 626, 
May 1909. 

Patel: Osteomes developp(is dans les tendons d’Achille. Lyon Chir., XXVIII, 351, 
1931. 

PiNARD, Vernier, et Abricosof: Osteophytes des tendons d’Achille. Presse M6d., 
XXXVII, 918, 1929. 

Sainton, Paul, bt Peron, Noel: T5nosite ossifiante et tabes. Paris Med., XL\, 342, 
1922. 

Steiger, W. : Ein Fall von ivahrer Knochenbildung in der AchiUessehne; ein Beitrag zur 
Frage der Tendinitis ossificans. Wiener klin. Wchnschr., XXXVIII, 1012, 1925. 

VoLKMANN, J.: Uber Verknocherungen in der AchiUessehne. Ztschr. f. orthop. Chir., 
LX, 110, 1933. 


the journal of bo.ve and joint surgery 



INTRA-ARTICULAR DISPLACEMENT OF THE INTERNAL 
EPICONDYLE FOLLOWING DISLOCATION 

BY ALEXANDER P. AITKEX, M.D., F.A.C.S., BOSTON, MASSACHUSETTS, AND 
HAROLD M. CHILDRESS, A-B., M.D., DALLAS, TEXAS 

Although the subject has been described by others, the frequency 
■«-ith which the internal epicondylar epiphysis is displaced into the joint 
follo'ft'ing dislocation of the elbow, especially in childhood, has not been 
fully recognized. Within the last ten months six such cases have been 
seen bs’^ the authors. The danger of this complication lies not only in the 
loss of motion of the elbow joint but also in the great possibility of per- 
manent damage to the ulnar nerve. Two of our patients entered the 
hospital because of such paratysis. 

The medial epicondjde is a rounded prominent projection of the distal 
humerus. Lying outside the joint capsule, it has a separate epiphysis 
which appears at the fifth year and fuses at the eighteenth. It serves as 
the common origin of the fiexor group of forearm muscles and as the at- 
tachment of the anterior and posterior portions of the ulnar collateral liga- 
ment of the capsule. The ulnar nerve lies in a shallow groove on the pos- 



Fig. l-.A. Fig. 1-B 

Posterolateral dislocation of the elbow. Note the epiphysis of the internal 
cpicondyle lying directly over tlie olecranon fos.-^a in tlie lateral view and between 
the shaft and ulna in the anteroposterior view. 


voi.. XX. xo. 1. j.\xr.\nv loss 


IGl 




162 


A. P. AITKEN AND H. M. CHILDRESS 



Fig. 2-A Fig. 2-B 

Right elbow (normal). Note the Left elbow. Note the epiphysis of 
relationship of the epiphysis to the the internal epicond 3 ']e Jjbng in the 
shaft and the width of the normal joint elbow joint, and the increase in width 
space. of the joint space. 

terior surface of the epicondyle and is attached to it by fascial bands. 
Distal to the epicondyle the nerve enters the flexor muscles a short dis- 
tance below their insertion to the epicondyle. 

A fall upon the hand, with the forearm abducted and the elbow 
slightly flexed, is apt to cause posterior or posterolateral dislocation of the 
elbow. Such a fall also exerts a pull upon the common flexor tendon and 
the ulnar collateral ligament, both of which are attached to the internal 
epicondyle. As a result, an avulsion of the epicondyle at the epiphysis 
occurs. The fragment is then pulled downward and forward by the 
flexors. The entire fragment, free of the humerus, is then carried back- 
ward and laterally with the displaced ulna, so that it lies posterior to the 
trochlea and anterior to the semilunar notch of the ulna. 

In the reduction the epicondyle is thus in a position either to drop into 
the notch or to be forced in as the humerus slides backward into the notch. 
The epicondjde, locked within the joint, carries with it the insertions of the 
flexor muscles and the ulnar nerve. The nerve is thus apt to be crushed 
between the bone surfaces, or, more commonly, severely stretched and 
constricted either by the fascial bands vdiich bind it to the epicondyle or at 

THE JOURNAL OF RONE AND JOINT SURGERY 


INTRA-ARTICULAR DISPLACEMENT OF THE INTERNAL EPICONDYLE 163 



Fig. 2-C 

Lateral view of right elbow (normal). 
Note the width of the joint space. 
The epicondyle can be seen through the 
joint space, but it is not within the joint. 


Fig. 2-D 

Left elbow. Note the increase in 
width of the joint space and the 
presence of the epiphysis within the 
joint. 


the point where it enters the flexor muscles. When such a displacement 
occurs, immediate reduction is imperative if severe or permanent nerve 
damage is to be avoided. Early postreduction roentgenograms, inter- 
preted vdth special attention to the position of the internal epicondyle, are 
the best safeguards against later nerve changes and a poor functional end 
result. In Figure 2-B the internal epicondyle was interpreted by two 
roentgenologists as an anomalous epiphysis of the olecranon. In case of 
doubt, it is well to x-ray both elbows in the anteroposterior and in the 
lateral views. The position of the epicondyle and the presence of anom- 
alous epiphyses can then be readily determined. 


DIAGNOSIS 

Reliance should be placed more upon a roentgenographic study than 
upon symptomatology. If the patient is seen early, palpation should re- 
veal the absence of the medial epicondyle and even the roughened bed of 
the fragment. The elbow is carried in a partially flexed position. There 
is moderate loss of flexion, as well as marked loss of extension. There is a 
slight increase of the carrjdng angle. Most of our patients were seen 


VOL. XX. XO. 1. JAXt.WlY 103S 




164 


A. P. AITKEN AND PI. M. CPIILDRESS 



Fig. 3-A Fig. 3-B 

The epiphysis of the internal epicondyle lies within the joint. Note the increase in 
width of the joint space in both views. 


several hours after the dislocation of the elbow had been reduced. ^ In 
these cases the joints were so swollen and painful that the physical findings 
were of little aid in making the diagnosis. 

In the roentgenograms the medial widening of the joint space with an 
absence of a normally situated medial epicondyle is diagnostic. (See 
Figures 1-A, 1-B, 2-A, 2-B, 2-C, 2-D, 3-A, 3-B, and 4.) In each of these 
cases the fragment was plainly seen interposed between the trochlea and 
the olecranon. According to other writers, this finding is not always 
present, especially in patients under seven years of age, at which time the 
medial epicondyle is mostly cartilage. 

Immediate ulnar-nerve signs are usually not present unless the neive 
has been subjected to excessive trauma during reduetion or at the time o 
injury. Usually, if present, they Avill not be noticed by the patient un ess 
attention is directed toward them by the examiner. After the acute leac 
tion and pain at the elbow have subsided, the patient becomes awaie o 
the areas of anaesthesia and muscle weakness. In the majority of cases, 
nerve symptoms — both sensory and motor — increase in intensity, ® 

the constriction produced by the fascial attachments extending fiom le 
nerve to the imprisoned epiphysis. Cotton reported three cases vi i 
definite neural signs, in one of which the nerve had been drawn into le 
joint and was lying alongside the avulsed fragment. Four of the ve pa 
tients whose cases were studied by Wilson had ulnar-nerve para ysis o 
varying degrees. In our group three of the six iiatients had symp oins o 
ulnar-nerve pressure. 

THE JOURNAL OF BONE AND JOINT SURGER 





INTRA-ARTICULAR DISPLACEMENT OF THE INTERNAL EPICONDYLE 165 

TREATMENT 

If the dislocation has been reduced and the fragment lies within the 
joint, the only treatment is immediate surgical reduction. It is not possi- 
ble to manipulate the epicondyle out of the joint unless the elbow is redis- 
located. Although successful in this manoeuver, one may by such forced 
manipulation seriously injure the exposed nerve. If, however, the pa- 
tient is seen before the dislocation has been reduced, it may be possible to 
keep the medial side of the joint open during manipulation and thus per- 
mit the fragment to escape. This did occur in one case in which roent- 
genograms before reduction showed the epiphysis pulled down and later- 
ally to a position beneath the trochlea. Accidental reduction occurred 
while the patient, holding his 
injured arm at the wrist, sat 
down on a chair. The frag- 
ment was thrown clear and 
later roentgenograms showed 
it near its original location. 

Surgical approach to the 
fragment is best made through 
a three-inch posteromedial 
curved incision extending 
from the epicondylar bed 
down over the medial aspect 
of the joint. The nerve is 
found posterior to the fracture 
surface of the humerus and 
should be followed distally to 
the point where it enters the 
joint. The flexor muscles are 
then identified and can readilj'^ 
be seen to enter the joint. 

The forearm is then abducted 
at the elbow to widen the 
joint space medially, while a 
curved periosteal elevator is 
placed under the muscles 
where they enter the joint. 

By traction on the muscles by 
means of the elevator, the 
fragment is easily reduced. A full range of motion slioulcl follow. 

The fragment maj'' be excised or reattached. In cither ca.se the com- 
mon flexor tendon is sutured either to the periosteum or to the lunneriis 
through a drill hole. Fixation maj’’ be performed bj' means of a nail. As 
the epiphysis in question contributes only to the growth of the epicondyle. 
growth disturbance because of excision or internal fixation is of no clinical 
importance. 



Fig. 4 

The epiphysis lies within the joint. 


VOI, XX. so I, J.VXCAUY iras 




166 


A. P. AITKEN AND H. M. CHILDRESS 


In all cases it is well to transpose the ulnar nerve anteriorly. This is 
done to prevent further damage to the nerve either by rubbing over the 
roughened epicondylar bed of the humerus or by becoming caught in the 
fibrous tissue during healing of the fracture. 

Following operation, the arm is immobilized in flexion with pronation 
of the forearm either in a sling or in a posterior plaster shell. Motion may 
be started in from three to four weeks. 

SUMMARY 

1. Intra-articular displacement of the internal epicondylar epi- 
physis may complicate elbow dislocations in children with injury to the 
ulnar nerve. 

2. Postreduction roentgenograms of all elbow dislocations should be 
taken to rule out this complication. 

3. Immediate surgical reduction is the best course, although closed 
reduction is possible if the medial joint space is widened during manipu- 
lation. 

4. Anterior transplantation of the ulnar nerve is advisable whether 
the epicondyle is excised or reattached. 

5. An excellent end result may be expected if the condition is treated 
promptly and correctly. 


REFERENCES 

Cotton, F. J. : Elbow Dislocation and Ulnar Nerve Injury. J. Bone and Joint Surg., 
XI, 348, Apr. 1929. 

Higgs, S. L. : Fractures of the Internal Epicond 5 de of the Humerus. British Med. J., 
II, 666, 1936. 

Wilson, P. D.: Fractures and Dislocations in the Region of the Elbow. Surg. Gynec. 
Obstet., LVI, 335, 1933. 


THE JOURNAL OF BONE AND JOINT SURGERl 



THE USE OF AMNIOTIC-FLUID CONCENTRATE 
IN ORTHOPAEDIC CONDITIONS * 

BY MANDELL SHIMBERG, M.D., M.R.C.S. (eNG.), L.R.C.P. (lOND.), 'WADS'WORTH, 

KANSAS 

From the Veterans Administration Facility, Wadsworth 

In 1927 Johnson reported on the use of human and bovine amniotic 
fluid as an agent which would stimulate the defense mechanism of the 
peritoneum. The human amniotic fluid obtained at cesarean section was 
at first employed, but later a concentrate prepared from bovine amniotic 
fluid was substituted. Considerable literature exists regarding the use of 
this concentrate within the abdomen. It shows that the introduction of 
the concentrate vdthin the peritoneal space excites the early production 
of a defense exudate; that it produces a reaction simulating the normal 
process of repair; and that it inhibits the development of a dangerous 
peritonitis.® There is also some evidence to show that its use prevents, or 
at least minimizes, postoperative adhesions.^- Personal experience 

in the use of this concentrate within the abdomen is in agreement vdth 
these conclusions. 

Three j’-ears ago the thought occurred to the author that, if the amni- 
otic concentrate was effective in hastening the process of repair within the 
peritoneum, it ought to be of value in other serous cavities, including 
those of the body joints. Therefore, a study of the use of amniotic-fluid 
concentrate within the joints under varying conditions has been made. 
This report is the result of that study. 

The composition of amniotic fluid is that of a hypotonic liquid, with 
a specific gravity never above 1.010. It contains coagulable albumin, 
cholesterol, histidine, lysin, allantoin, certain inorganic compounds, and 
varying amounts of mucin. The work of Cantarow, Stuckert, and Davis 
shows that the fluid is not urine or a serum dialysate, but a true product 
of the amniotic cells. 

There was used in the work upon whicli this report is based an 
amniotic concentrate now on the market. This product is obtained b 3 ^ 
concentrating, fractionating, and purifjdng the amniotic fluid of cows 
which arc from two to four months pregnant. At this period of irovine 
gestation, it is unlikelj’’ that contamination of the fluid would occur, and, 
unlike the human foetus, there is no possibilit}" of urine contamination 
from the calf.® 

It is of importance to know that Johnson demonstrated tliat this 
fluid is harmless when injected intraperitoneall}*.® In tliis work no ill 
effects have followed its use in the joints. The concentrate emploj'ed is 

* Published with the permission of the Medical Director of the Veterans .-tdininis- 
tration, who assumes no responsibility for the ojiinions cxpre.ssed or the conclusions drawn 
by the writer. 


VOL, X.X. NO. I. JANIWUY IP3S 


107 



168 


MANDELL SHIMBERG 


superior to the whole amniotic fluid because in its preparation the proteiii 
content is reduced, and it is rendered sterile and stable. 


CLINICAL APPLICATION 

The total number of cases in which the concentrate was used within 
joint cavities was sixty-eight. These cases may be classified as follows: 


Types of Cases iVo. of Cases 

Arthrotomies (clean) 26 

Closed manipulation of joints. . 12 

Fractures involving joints 8 

Fractures adjacent to joints 7 

Joint effusion (etiology unknown) 4 

Joint effusion (gonorrhoeal) 1 

Atrophic arthritis S 

Sympathetic joint effusion 1 

Subacute joint infection 1 


There were twelve cases in which amniotic concentrate was used on 
tissues outside of joints. 

The joints in which amniotic concentrate was used were as follows: 


Joint 
Knee. . . 
Shoulder 
Elbow . . 
Hip. . .. 
Ankle. . . 
Wrist. . . 


No. of Cases 
... 46 

. . 8 
. . 6 
. . 5 

. . 2 
.. 1 


ARTHROTOMIES (cLEAN) 

For some time past the procedure of introducing amniotic concentrate 
into all joints after intra-articular surgery has been emifioyed. 

Technique: After the necessary surgery has been completed, a moder- 
ate-caliber needle is introduced well into the joint space, and the joint is 
completely closed around the needle; this includes skin closure. The 
concentrate is then introduced in sufficient amount to distend the joint 
cavity with the fluid. This requires varying amounts of the liquid. 
In the knee joint as much as 100 cubic centimeters has been injected. 
The amount used varies with the individual joint. Enough fluid is intro- 
duced to cause separation, even if minimal, of the articulating surfaces. 

Warren has demonstrated experimentally that the absorption of the 
concentrate within the peritoneal cavity proceeds as follows: The fluid 
introduced drops in content one-half during the first four hours; there is 
15 per cent, left at the end of twenty-four hours; and it has completely 
disappeared within forty-eight hours. It is believed that the rate of 
absorption within joints is somewhat slower. The concentrate is ab- 
sorbed rapidly at first, but at least 25 per cent, remains at the end o 
twenty-four hours, and it may be as long as sixty hours before complete 

absorption has taken place. . 

Warren has also made the interesting observation that the peno o 

THE JOURX^L OF BO-VE AXD JOIN’T .SURGEIFV 



AMKIOTIC-FIiUID COIsCENTRATE IN ORTHOPAEDIC CONDITIONS 169 


oozing of a traumatized peritoneum is reduced by half when the amniotic 
fluid is employed. A similar action takes place on injection of the concen- 
trate into a joint ca^^t 3 ’■, and this is a factor of prime importance in intra- 
articular surgerJ^ 

Johnson, in expeiimental work with the concentrate in the peritoneal 
ca\dtj'’,* showed that a maximum wliite-cell response occurred within 
twelve hours. He found an impressive subserous oedema with a minimal 
hemorrhagic response, as shown by the merelj’' pinkish exudate. This 
exudate was rich in fibrin, and, if i\*ithdrawn after four hours, it jelled 
immediately. Later on, as the total white-cell count receded, a variable 
percentage of histiocytes was found. 

In two cases in which joints were aspirated after the introduction of 
the concentrate, it was found that in one case, after four hours, the aspir- 
ated fluid jelled almost immediately, thus demonstrating its high fibrin 
content. The total cell count was 22,000 with 95 per cent, neutrophiles. 
In the second case, in which the fluid was aspirated at the end of twenty- 
six hours, the total count was 12,400 with 45 per cent. histioc 5 ’tes. It 
would, therefore, seem plausible, as Johnson has pointed out, that the 
concentrate speeds up considerablj’’ the normal process of defense repair. 
Collins has shown that normal s 3 mo^ual fluid contains a mucin protein, 
and that the function of the mucin is to increase \ascosity.- Jones has 
demonstrated that the function of an 3 '^ joint is dependent on the fluid 
pressure film of the s 3 movial fluid, and that one factor in the proper main- 
tenance of such a pressure film is the viscosity of the lubricant. Since 
amniotic concentrate contains mucin, it is logical that it would act as a 
joint lubricant. 

In attempting to explain the 7nodus operandi of amniotic concentrate 
after surgery within joints, it would be fair to state that it (1) reduces 
oozing time to a minimum, (2) excites a brisk defense-repair effort, (3) 
increases ^^scosit 3 '■ and acts as a lubricant, and (4) operates mechanicall 3 ' 
to separate traumatized joint surfaces. 

Clinically it was observed in these twent 3 ’'-six cases that post- 
operative pain was reduced to a minimum. As compared with cases in 
which the concentrate was not used, this difference was striking. No 
postoperative infection occurred in an 3 '^ case, but the significance of this in 
clean-joint surger 3 ’^ is slight. No postoperative adhesions occurred in an 3 ' 
case. In all twent 3 ’’-six cases the final functional result could be fairl 3 ' 
rated as “good” to “excellent”. It was found that function was more 
easil 3 ’- and rapidl 3 ’’ restored when the concentrate was empIo 3 'ed. In four 
cases it was deemed necessar 3 ' to refill the joint. In nineteen ca.?cs the 
temperature postoperativel 3 ' did not reach 100 degrees; in five cases it 
reached 100.2; and in two cases it went as iiigh as 101. The S 3 -stemic 
white count in twent 3 ' cases showed a postoperative Icukoc 3 'tosis of be- 
tween 10.000 and 15,000. This, however, in view of the ojicrativc trauma, 
is of little significance. In no case was there observed a patliologica! 
effusion after snrgciy. 

VOL. .\X, N'O. 1. JAN'i;.\nY I93S 



170 


MANDELL SHIMBERG 


The absence of complications following twenty-six arthrotomies after 
using amniotic-fluid concentrate, as compared with those reported by 
Swett in 100 arthrotomies without its use, may or may not be significant. 
(See Table I.) 


TABLE I 

Comparison of Twenty-Six Arthrotomies after Use of Amniotic-Fluid Concen- 
TRATE (ShIMBERG) WITH 100 ArTHROTOMIES WITHOUT ItS UsE (SwETt) 



Without Amniotic- 

Following Amniotic- 


Fluid Concentrate 

Fluid Concentrate 

Postoperative Complications: 



Death 

. . . . 0 cases 

0 cases 

Infection 

. . . . 0 cases 

0 cases 

Excessive effusion 

. . . . 7 cases 

0 cases 

Adhesions and delayed I'eturn of motion . 

. . . . 7 cases 

0 cases 

Manipulation to restore motion 

. . . . 4 cases 

0 cases 

Recovery Period: 



Duration of bed treatment (average) . . . . 

, . . . 9 daj’s 

5 days 

Duration of use of crutches (average) . . . . 

16 days 

11 daJ^s 

Recoverj'^ of functional use (average) . . . . 

9.5 weeks 

4 weeks 

End Results: 



Full recovery 

95 cases 

25 cases 

Slight remaining disability 

5 cases 

1 case 


CLOSED MANIPULATION OP JOINTS 

In these twelve cases, for one reason or another, it was deemed advis- 
able to break down joint adhesions by maniijulation under anaesthesia. 
Previous experience with such forcible manipulation had been unsatis- 
factory in that severe postoperative pain had occurred, and usually there 
had been a return of adhesions and disability. In these cases, after 
manipulative procedure, the joint in question was filled under the strictest 
asepsis with the concentrate. As much fluid as iiossible, without causing 
undue capsule stretching, was introduced. In joints other than the knee, 
technical difficulties were encountered, for most joints are difficult to enter 
with a needle unless an effusion is present. In the hip joint an antero- 
lateral approach was used, the needle following the femoral head into the 
joint space. The shoulder joint was entered in a similar manner. A 
posterior approach to the elbow and wrist joints proved sati.sfactory. 
The ankle joint was entered lateral to the internal malleolus. 

Case 36. The patient, a male, aged thirty-eight, gave a history of gradual stiffening 
of the right shoulder with no known trauma. Roentgenographic examination was nega- 
tive. Phj^sical examination disclosed inability to abduct the slioulder beyond 45 de 
grees; the scapula moved simultaneously with the arm. Circumrotation was maikec } 
limited and painful. There was no evidence of gonococcal infection. There was severe 
pyorrhoea. The sedimentation rate w'as 12. 

The pjmrrhoea was given adequate treatment, and, under anaesthesia (evipan), le 
shoulder was manipulated and dense adhesions wore broken up. Twenty cubic cen i 

the journal of bo.ne and joint surgery 


AMNIOTIC-FLUID CONCENTRATE IN ORTHOPAEDIC CONDITIONS 171 


meters of concentrate was introduced into the shoulder joint, and twenty-five cubic 
centimeters placed in the peri-articular tissues. The arm was superabducted and ele- 
vated when the patient returned to bed, and kept in that position for twenty-four hours. 
There was no complaint of excessive pain. After a period of twenty-four hours, all 
restraint was removed, and the patient was encouraged to move the arm as much as 
possible. No physiotherapy was prescribed. At fii'st the shoulder could be moved in 
all planes with ease. Then there occurred a period of some stiffening, but within ten 
days the patient had a 90-per-cent, range of motion with but slight pain. 

The patient was seen six months after discharge and stated that he had returned to 
his job as an automobile salesman, and that he had no trouble whatsoever with his arm. 
Examination did not reveal any abnormality of the shoulder. 

In these cases it has not been found necessary to do a remanipulation, 
although in four there was administered a second injection of the concen- 
trate after the operation. In only one case was there failure to achieve a 
moderately good or excellent result. The author fully agrees with the 
generally held opinion that in so-called idiopathic stiffening of a joint, such 
as the shoulder, the majority of the adhesions are extra-articular. This is 
the reason for the procedure of infiltrating the peri-articular structures. 
No untoward result from introducing the concentrate into tissues outside 
the joint has been observed. 

FRACTURES INVOLVING JOINTS 

In this type of fracture there is considerable joint trauma with bloody 
effusion, and the end result, in previous e.xperience, has been unsatisfactory 
in the majority of cases. 

In the eight cases reported the concentrate was employed with uni- 
formly good results. 

Case 67. A male, aged forty-two, fell from a cherry tree, sustaining a severe injury 
of the right knee. He was seen within a few minutes after the fall. Roentgenographic 
examination showed that he had a spread-eagle fracture of the tibial head with multiple 
fissures extending into the joint, as well as a lateral dislocation of the tibia on the femur. 
A considerable joint effusion was present. 

Under anaestliesia, the dislocation was reduced, altliougli tiiere was a tcndencj' to 
redislocate. Due to the spreading of the tibial head, a Carrel screw was inserted, and the 
fragments were brought firnilj- together. Tlie joint was aspirated, and fifty cubic centi- 
meters of veiy bloody fluid was removed. This was replaced bj' seventy-five cubic 
centimeters of the concentrate, and a cast was applied. There was little postoperative 
pain. No narcotic was required. 

At the end of five weeks, the cast and the Carrel screw were removed. At this time 
there was 25 per cent, active motion of the knee joint. Physiotherapy in the form of 
diathermy, massage, and active movement was instituted. The patient re.sumed full 
work without any support at the end of eight weeks and two daj's, with So per cent, of 
full function. In three months the function had returned to normal. 

In case, in spite of proved severe joint trauma, there was com- 
plete healing and return of normal function within an uiiusualh' short 
time. Similar results have been obtained in seven other cases of varying 
degrees of severity, in which the knee was involved in five cases, the shoul- 
der in one case, and the ankle in two instances. It is felt that these results 
lend sup])ort to the theory that the concentrate excites an early defensc- 

VOI.. XX. XO. 1. JANCARY 1038 





AIINIOTIC-FLTJID CONCENTHATE IN ORTHOPAEDIC CONDITIONS 173 


gonococcal infection existed. The knee had been aspirated twice before admission, but 
no information as to the type or amount of fluid removed was available. 

The knee was aspirated soon after admission, and seventy cubic centimeters of a 
clear, thin, non-coagulable fluid was obtained. Its speciflc gravity was 1.015, and the 
fluid contained 1500 cells per cubic centimeter, 15 per cent, of which were neutrophiles. 
The joint was fiUed vith seventy-five cubic centimeters of concentrate. After seventy- 
two hours there was no fluid remaining in the joint, and no return of the effusion occurred. 

In the other three cases also, one filling of the concentrate was suffi- 
cient to prevent the reappearance of an effusion. 

Collins states that, when the same joint is aspirated twice within a 
few days, there is a change in the viscosity of the fluid and the second 
“diluted”, less viscous fluid is more amenable to natural absorption than 
the original effusion.® Whether the concentrate exerts some biological 
action in these cases, or whether there is a purely physical action con- 
cerned, involving surface tension and viscosity, is a matter of speculation. 

JOINT EFFUSION (gONORRHOEAl) 

Case 42. The patient was a male, aged forty-six, who for years had had trouble 
with the right knee, and his histoiy showed a gonococcal background. A gonorrhoeal 
arthritis seemed probable, even though the bacteriological study was negative. The 
knee, when first seen, was swollen, painful, and slightly hot to the touch. There was no 
temperature rise or increased systemic white count. There was a moderate amount of 
fluid in the joint, and the synovial membrane was definitely thickened. The roentgeno- 
graphic findings were as follows: “There are punched-out areas along the outer margin of 
the knee joint and a destruction of cartilage as shown by the almost complete obliteration 
of the inner portion of the joint space.” 

Aspiration of the knee was performed and ninety cubic centimeters of thick green 
fluid was obtained. This did not coagulate. Examination of the fluid showed a consid- 
erable number of pus cells, but no organisms. A cultm-e was sterile. Ninety cubic 
centimeters of concentrate was placed in the joint. Twelve days later there was a mod- 
erate effusion in the joint. This was aspirated and fifty cubic centimeters of clear, 
quickly coagulable fluid was obtained. This fluid showed but few pus cells, with a total 
white count of 14,500 and 67 per cent, neutrophiles. 

There was a definite change in the character of the fluid following the use of the con- 
centrate. After the second injection, there was no marked accumulation of fluid within 
the joint. The patient stated that his knee felt better than it had for some time past, 
but there still remained considerable joint patholog 3 '. 

ATROPHIC ARTHRITIS 

In atrophic arthritis the joint manifestations are but local out- 
croppings of a profound sj'^stemic disease. It is logical to assume that, 
even though the systemic aspects of the disease maj’’ be brought well 
under control, the pathology initiated in the joints, being of an inflamma- 
tory character, will go on to some degree of joint damage. 

In six cases of subacute atrophic arthritis, in which there was either 
joint effusion or marked pathologj' of the synovial membrane, the con- 
centrate was used in an effort to limit the damage. Timbrell Fisher has 
reported excellent results in such cases with arthrotoni}' and lavage with 
Dakin solution. In this studx- the knee joint was entered with a needle, 
and such fluid as was present was withdrawn and replaced with a larger 

VOL. XX. XO. 1. JAXUAUY I03S 



172 


MANDELL SHIMBERG 


repair effort -with resolution without adhesions, and also that it quickly 
seals oozing traumatized joint tissues. Jones found that the pressure 
film of synovial fluid could withstand a load which would crush bone. 
In intra-articular fractures, it is reasonable to assume that even that 
resistant pressure film may be broken. It is also logical to believe that 
the amniotic concentrate restores the pressure film, so that the lubricant 
effect so necessary to normal function can once more operate. 

In the case cited, there existed circumstances which made continuous 
hospitalization impossible. Consequently, but one filling of the concen- 
trate was made. In four other cases the filling was repeated once in three 
cases and twice in the remaining case. A refill within sixty hours of the 
first injection of the concentrate is deemed generally advisable. The case 
in which three fillings were made was a severe crushing of the patella with 
injury to the femoral patellar facet. It was a compound fracture in which 
open operation Avas performed. In spite of the devitalized condition of 
the tissues, after a debridement and concentrate injection, first-intention 
healing and an 80-per-cent, normal end result were obtained. 

In this type of fairly common injury, Avhere good end results are so 
difficult to obtain, and Avhere prolonged hospitalization and treatment are 
so often necessary, it is believed that the use of the amniotic concentrate 
is of distinct value. 


FRACTURES ADJACENT TO JOINTS 

In each of these seven cases there was a fracture adjacent to a joint, 
and, Avhile there Avas no eAudence of bony intra-articular injury, yet it Avas 
believed that some trauma to the joint tissues had occurred. In these 
cases, after reduction, a cast AA^as applied and a AAondoAV Avas cut over the 
nearby joint, through AAdiich from one to three fillings of the joint with the 
concentrate Avere made. 

The functional results in these cases were excellent, and it Avas found 
that immediately after removal of the cast there Avas more than usual 
joint function. This procedure Avas prompted by the thought that amni- 
otic concentrate might be of value in the treatment of closed fractures 
where there aa^s reason to suspect some joint trauma. 

JOINT EFFUSION (ETIOLOGY UNKNOWN) 

There are certain types of joint effusions, especially in the knee, in 
Avhich there is considerable doubt about the etiology. The four cases 
included under this head Avere ones in Avhich a joint effusion had appealed 
and persisted, and in Avhich there was no knoAAm etiological factor. In all 
cases, the knee AAms iiiAmlved, and, in two instances, there had been scA'^eral 
aspirations AAuth reappearance of the fluid. After aspiration of the exist- 
ing joint fluid, the joint caAuty Avas distended with the concentrate in each 
case. 

Ca.se 4. A male negro, aged forty-six, gave a history of fairly sudden sw elling of 
the right knee with accompanying pain. The Wassermann test was negative, ut 


THE JOURNAL OF BONE AND JOINT SURGF.RY 



AMNIOTIC-FLUID CONCENTRATE IN ORTHOPAEDIC CONDITIONS 175 


concentrate. The temperature dropped to normal after three daj’^s. There was no 
further effusion and the patient recovered. 

No conclusions may be drawn from this one case, but it is thought- 
provoking. 

THE USE OF AMNIOTIC CONCENTRATE ON OTHER THAN JOINT TISSUES 

In four cases of slow-healing fractures, the concentrate was injected 
into the fracture site. Without a large controlled series it is impossible to 
evaluate the results obtained, but the clinical and roentgenographic evi- 
dence tended to show that the fluid was a stimulant of bone repair. This 
impression is in agreement vdth the experimental work of Morrison, John- 
son, and Hazard. This procedure is definitelj'^ worthy of further clinical 
trial. 

In eight other cases the amniotic fluid was used in soft tissues for 
various reasons. It was injected under the lumbar fascia for the forcible 
breaking up of adhesions. This procedure was suggested by Dr. Charles 
Murray Gratz of New York. As yet no decision has been reached as to 
its value for this purpose. It is again emphasized, however, that the use 
of the concentrate within soft tissues has never caused the slightest un- 
favorable reaction. It was used in a case of free skin graft with good re- 
sults, also in two cases of moderate burns in which it appeared to have a 
mild anaesthetic effect. Its use in soft tissues, it is believed, might be 
considerablj’' extended. 

DISCUSSION 

From the evidence submitted, amniotic-fluid concentrate appears to 
influence favorably the mechanism of defense repair. Its composition 
gives but meager information upon which to formulate a theory which will 
satisfactorily account for its beneficent action. It is true that it contains 
allantoin in small amounts, and there is evidence to show that allantoin is 
of value in promoting repair. It is to be considered that amniotic fluid is 
a true body fluid, and one of its functions is to prevent adhesions between 
the foetus and the amniotic sac.^® There is also reason to believe that its 
action is not merely mechanical, but also biological.® Its use within 
joint cavities accomplishes several purposes. First, it distends the cavity 
with an innocuous fluid, and this mechanical distention separates to some 
extent the injured surfaces. This, after all, is probably nature’s reason 
for creating an effusion in response to trauma or irritation. Secondlj'', it 
excites an immediate defense reaction in the intra-articular tissues with 
the formation of much fibrin, and at the same time reduces oozing time to 
a minimum. Further, as the defense reaction wanes, a repair process is 
stimulated. Apparently the normal bodj’- process of defense and repair is 
speeded up with a resultant earlj' resolution, thereby' limiting fibrous 
adhesions. Thirdly, the fluid influences intra-articular viscosity, and the 
lubricant factor in joint function is favorably affected. The results ob- 
tained by arthrotomj' after injection of this fluid in this study comjiare 
favorably with those of others as regards postoperative complications, 

VOL, XX. XO. I. JAXCAnV 103S 



174 


MANDELL SHIMBERG 


volume of the concentrate. This procedure was repeated from two to 
seven times. In an as yet unpublished paper on “Arthritis”, a detailed 
report of these cases will be given. It suffices here to say that the results 
in the cases where the concentrate Avas used were satisfactory. The 
symptoms cleared up, and during the period of hospitalization the im- 
provement Avas maintained. 

In this connection, consideration must be giA'^en to the AAmrk of 
Keefer, Holmes, and Myers on the inhibition of tryptic digestion of carti- 
lage by synovial fluid from patients AAuth various forms of arthritis. They 
state that the antitryptic substances in the synovial fluid stop cartilage 
destruction. It is possible that the concentrate contains such elements. 

The concentrate AAms used in tAAm cases AAdiere the arthritic process 
had burned itself out and had left crippled, dry joints. After the correc- 
tion of a flexion deformity, from one to fiAm injections of the concentrate 
AAmre made. It is belicAmd that by this procedure fairly good joint func- 
tion AA^as established. This is an extensive field for further study. 

Again it seems justifiable to assume that the defense-repair mechan- 
ism excited by the amniotic fluid had, as its end result, a resolution of 
joint pathology AAuthout fibrous adhesions. 

SYMPATHETIC JOINT EFFUSION 

It is well knoAATi that pathology in the Aucinity of a joint will at times 
incite a sympathetic joint effusion, as illustrated by the folloAAung case. 

Case 39. The patient, a male, aged forty-four, gave a history of attacks of pain in 
the loAver right thigh. During the last attack his knee had become swollen and painful. 
Roentgenographic examination showed a small, Avell-circumscribed Brodie’s abscess in 
the lower end of the right femur close to the joint. The joint was hot, tender, and pain- 
ful. A moderate effusion existed. 

Aspiration M’^as performed and forty-five cubic centimeters of clear, non-coagulable 
fluid Avas removed, AA^hich shoAA^ed a total AA^hite count of 1800 and 21 per cent, neutro- 
philes. The fluid Avas bacteriologically sterile. These findings agree Avith those of 
Collins in similar effusions.^ Sixty cubic centimeters of concentrate Avas introduced into 
the joint, and the patient stated that the knee became comfortable almost at once. In 
sixty hours the joint fluid was negligible, and there Avas no discomfort in the thigh. 
Roentgenographic findings did not change. The final result in this case is not knoAvn. 

SUBACUTE JOINT INFECTION 

There is reason to believe that amniotic concentrate exerts some bac- 
tericidal effect. The only literature on the subject is unavailable. 
However, the following case is of some inteiest in this connection. 

Case 10. A male, aged forty-seven, developed a SAvollen and painful left knee AAuth- 
out knoAA'n cause. The temperature varied from 99.S to 100.8. 

The knee was aspirated and sixty-five cubic centimeters of cloudy fluid was wit i- 
draAvn. Tliis fluid contained many pus cells, and culture shoAved numerous colonies o 
staphylococcus aureus. Seventy cubic centimeters of amniotic concentrate Avas in- 
jected. Taa'o days later there was a moderate effusion, and at that time forty cu ic 
centimeters of fairly clear fluid was withdraAAm. It contained feiver pus cells with t e 
organisms less numerous. The fluid AA'as replaced AA'ith fifty cubic centimeters of t e 


THE JOURNAL OF BONE AND JOINT SURGERA 



amniotic-fltjId concentrate in orthopaedic conditions 177 


12. Lacey, J. T.: The Prevention of Peritoneal Adhesions Amniotic Fluid. Ann. 
Surg., XCII, 281, 1930. 

13. Lacey, J. T.; Amniotic Fluid. A Clinical Studj'. Ann. Surg., Cl, 529, 1935. 

14. Morrison, G. M.; Johnson, H. L.; and Hazard, J. B.: Promotion of Fracture 
Repair. J. Bone and Joint Surg., XIX, 425, Apr. 1937. 

15. S.ANTOM.AURO, U.: II potere battericida del liquido amniotico. Clin. Ostet., 
XXXVII, 449, 1935. 

16. SwETT, P. P. : Arthrotomy for Internal Derangement of the Knee. J. Bone and 
Joint Surg., XIX, 157, Jan. 1937. 

17. ' Uyeno, Doko: The Physical Properties and Chemical Composition of Human 

Amniotic Fluid. J. Biol. Chem., XXXVII, 77, 1919. 

IS. Warren, Shields: The Effects of Amniotic Fluid on Serous Surfaces. Arch. 
Pathol., VI, 860, 1928. 

ro. Williams, J. W. : Obstetrics. A Textbook for the Use of Students and Practition- 
ers. Ed. 5, p. 173. New York, D. Appleton & Co., 1923. 


VOL. X.X. NO. I. J.VNCAUV I93v 



176 


MANDELL SHIMBERG 


time of functional restoration, and final end results. In fractures of the 
intra-articular type, there is no doubt that the fluid has definite value. 
In atrophic arthritis it seems indicated where there is effusion or marked 
synovial-membrane involvement. 

It is realized that the number of cases reported is comparatively 
small, and that no definite conclusions can be drawn with any great degree 
of certainty. However, the observations made indicate that the use of 
amniotic-fluid concentrate has some value in orthopaedic disabilities. 

SUMMARY 

1. In sixty-eight cases in which amniotic-fluid concentrate has been 
employed in the treatment of various pathological conditions of joints, the 
use of the fluid concentrate has not been attended by a single unfavorable 
reaction. 

2. Its action is probably both biological and mechanical. 

3. It speeds up a defense-repair mechanism within the joints. 

4. The results obtained have been impressive in intra-articular 
fractures, and encouraging in selected cases of atrophic arthritis, as well 
as in persistent joint effusions. 

5. It successfully prevents the formation of new adhesions after 
closed manipulation of joints. 

6. It is a valuable prophylactic after arthrotomy of any type. 

7. Its use both in soft tissues and in other serous cavities is sug- 
gested. 

The advice and splendid cooperation of Dr, 0. B. Francisco during the research is 
much appreciated. 

REFERENCES 

1. Cantarow, a.; Stuckert, Harry; and Davis, R. C.: The Chemical Composition 
of Amniotic Fluid. A Comparative Study of Human Amniotic Fluid and Maternal 
Blood. Surg. Gynec. Obstet., LVII, 63, 1933. 

2. Collins, D. H.: Synovial Fluid in Chronic Arthritis. J. State Med., XLIII, 
652, 1935. 

3. Collins, D. H. : The Pathology of Synovial Effusions. J. Pathol, and BacterioL, 
XLII, 113, 1936. 

4. Fisher, A. G. T. : The Principles of Orthopaedic and Surgical Treatment in the 
Rheumatoid Type of Arthritis. J. Bone and Joint Surg., XIX, 657, July 1937. 

5. Johnson, H. L.: Observations on the Prevention of Postoperative Peritonitis and 
Abdominal Adhesions. Surg. Gynec. Obstet., XLV, 612, 1927. 

6. Johnson, H. L.: Amfetin. Its Influence upon Defense and Repair in Serous Cavi- 
ties. Med. Arts, XXXVI, 409, 1933. 

7. Johnson, H. L;: An Exposition of the Preparation and Administration of Amniotic 
Fluid Concentrate. New England J. Med., CCXII, 557, 1935. 

S. Johnson, H. L.: Peritoneal Immunization. Am. J. Surg., XXXIV, 266, 193 . 

9. Johnson, H. L.; Coonse, G. K.; Hazard, J. B.; Foisee, P. S.; and Aufranc, 
Otto: Amniotic Fluid Concentrate as an Activator of Peritoneal Immunity. Surg. 
Gynec. Obstet., LXII, 171, 1936. 

10. Jones, E. S.: Joint Lubrication. Lancet, I, 1043, 1936. 

11. Keefer, C. S.; Holmes, W. F., Jr.; and Myers, W. K: Inhibition of Tr3Ttic 
Digestion of Cartilage bj-- Sjuiovial Fluid from Patients with Various Tjpes o 
Arthritis. J. Clin. Investigation, XIV, 131, 1935. 

the journal of bone and joint surgera 



FKACTUHBS OF THE METACAHPALS 


179 


proximity to the metacarpophalangeal joint, control of the fragment 
becomes very difficult. (See Figures 3, 5, and 7-A.) 

In an individual who, because of his vocation, must firmly gi’ip some 
tool, such as a hammer, a saw, etc., the displacement causes undue pres- 
sure on the head of the metacarpal, with a resultant inability to work 
efficiently. In the case of a prize fighter, this malalignment prevents 
him from delivering a blow with full force. 

Up to the present time no solution of this problem has been found. 
The variety of treatments offered is ample proof of this fact. 

When any fracture is reduced, the distal fragment is brought into 
alignment with the proximal one and maintained in that position by some 
means of immobilization. 

In dealing with metacarpal fractures, excluding those in the proximal 
half of the shaft, there is no direct purchase on the small distal fragment, 
making it necessaiy for the surgeon to attempt reduction through the 
agency of the finger. However, between the proximal phalanx and the 
fracture site is the metacarpophalangeal joint, which has motion in all 
directions. This motion must be nullified before direct control of the 
fragment can be obtained. Extension of the finger does not produce 
this effect and, to make things worse, it increases the dorsal angulation. 
As is well known, extension makes the interosseous muscles taut and, 
since these muscles maintain the angulation, this pull on them will cause 
greater buckling of the fragments. 



Fig. 2-A Imo. 2-IJ 

Casol. After reduction and immobi- Case 1. Complete correction of t lie 
lization. Ulnar displacement corrected. donial aiiKulation. 


VOL. XX. XCI 1. J.\X1 AnV IMS 




FRACTURES OF THE METACARPALS 


A New Method of Reduction and Immobilization 

BY S. A. JAHSS, M.D., NEW YORK, N. Y. 


From the Hospital for Joint Diseases 


Fractures of the metacarpals, involving the four inner fingers, have 
always been a disturbing and vexing problem. Irrespective of the 
fracture site, the deformity is always the same, — namely, dorsal angida- 
tion. Since these bones are so comparatively superficial, the cosmetic 
result is rather unpleasant. There is a “bump” on the dorsum of the 
hand and, ivhat is even more important, there is a disturbance in the 
alignment of the knuckles, Iioth in the frontal and in the sagittal planes. 
The head of each metacarpal is quite prominent in the palm of the hand, 
due to the angulation of the distal fi*agment. Particularly is this true of 
fractures just proximal to the head. The small distal fragment dips 
sharply downward into the palm and, because of its shortness and its close 



Fig. 1-A 

Case 1. Fractures of fourth and fifth 
metacarpals; ulnar displacement of dis- 
tal fragment 'of fourth metacarpal; ob- 
lique fracture of fourth metacarpal. 

17S 



Fig. 1-B 

Case 1. Overriding and dorsal an- 
gulation of tlie distal fragment of the 
fourth metacarpal and some dorsal an- 
gulation of the fifth metacarpal. 

THE JOURNAL OF BONE AND JOINT SORGER1 



VOL. XX, NO. ] JANUARY, 1938 


Old Series 
Vol. XXXVI, No. 1 


The Journal of 
Bone and Joint Surgery 

SCOLIOSIS TREATED BY THE WEDGING JACKET 
Sklectiox of the Area To Be Fused 

BY FELIX L. BUTTE, M.D., NEW YORK, N. Y. 

Fellow of the New York Orlhopnedic Dispensary and Hospital 

This articlo is not intended as a comprehensive study of scoliosis, but 
as a study of representative cases in which some of the cardinal principles 
of jacket correction and spine fu-sion are briefly analyzed, particularly with 
reference to the selection of the area to be fused. In the five cases described, 
the following points are illustrated: 

1. The minimum fusion area must include every vertebra in the 
primary curve. There is an occasional exception to this rule in cases 
where one vertebra at one or the other end of the primary curve may be 
omitted from the fusion. The primary curvature is that curve in which 
the deforming factor is active and for which the other curve or combination 
of curves is compensatory. Occasionally there are two primary curvatures. 

2. The ideal fusion area is one which includes at least the minimum 
fusion area and in which the end vertebrae are parallel to each other and at 
right angles to the line joining their centers. In the final result the end 
vertebrae of such a fusion area will be parallel and transverse to the axis 
of the trunk. 

3. The actual determination of the fusion area — whether or not one 
or more vertebrae beyond the ends of the primary curvature should be in- 
cluded — is made after correction has been obtained by the wedging jacket. 

4. Overcorrection of a curvature and fusion in this position is to be 
avoided. 

5. Provided thereby compensation has been restored, remarkable 
improvement in clinical and roentgenographic appearance often results 
when the primary curve has been corrected less than 50 per cent. 

6. The value of the pelvic-tilt examination as described by Ferguson 
is emphasized. The patient sits unassisted with the hands resting on the 
knees; the pelvis is elevated on the side of the convexity of the lumbar 
curve as much as can be tolerated without causing the patient to lose bal- 
ance, usually three or four inches; and a roentgenogram is taken. 


1 



180 


S. A. JAHSS 




Fig. 3 

Case 3. Fracture of the fiftli meta- 
carpal just distal to the head. Note 
the marked dorsal angulation. 


Fig. 4 ■ 

Case 3. Pei-fect alignment after rC' 
duction. 


When the finger is flexed at the metacai’pophalangeal joint to an angle 
of 90 degrees, the head of the metacarpal is so firmly fixed to the base of 
the proximal phalanx by the collateral ligaments that any motion of that 
phalanx causes the head of the metacarpal to move along with it. In 
this position, by pushing upward or dorsally on the flexed finger, extension 
of the distal fragment is effected, correcting the dorsal angulation, even 
though the fragments are not handled directly. 

In the index and middle fingers this is easily accomplished, but in 
the ring and little fingers a slight difficulty is encountered, — a little more 
so in the fifth than in the fourth finger. It is necessary to push these 
fingers farther dorsally than the others. Upon investigation the reason 
for this is found to be elementary. In the carpometacarpal joint of the 
little finger there is extension of about 25 degrees, whereas in the ring 
finger this motion amounts to only 15 degrees. In the corresponding 
joints of the index and middle fingers there is no dorsal motion whatso- 
ever. AVhen upward or dorsal pressure is brought to bear on the head of 
the metacaipal through tlie flexed finger, the angulation cannot be over- 
come until the proximal fragment becomes fixed. Since there is no 
motion in the carpometacarpal joints of the inde.x and middle fingers, 
the proximal fragment is fixed physiologicallj'', and all the dorsal excursion 


THE JOURNAL OF DONE A.VD JOINT .“L'RGERY 




181 



Fio. 5 Fig. G-A Fig. 6-B 

Ciiso 7. Oliliriuc comininutccl fnicturu Ca.sc 7. After reduction. No Case 7. Perfect alignment of the frag- 

of the nei'k of tlic fiftlunctacarpnl. Dorsal dorsal angul.ation. inents. 

angulation and jialmar overriding. 




182 


S. A. JAHSS 



Fig. 7-A Fig. 7-B 


Case 8. Old malunited fi-acture of Case 8. Note shovtenipg of the meta- 
the index metacarpal with marked carpal. Compare with Fig. 8-B. 

dorsal angulation. Note shortening 
of the entire metacarpal. 

that is necessary for the alignment of the distal fragment is the arc of 
the angulation between the fragments. In the ring and little fingers 
this excursion is necessarily greater, since not only must the angulation 
of the fragments be overcome, but, in addition, the arc of extension 
traversed by the proximal fragment before it becomes fixed at the carpo- 
metacarpal joint. However, should the proximal fragment be fixed 
mechanically, no consideration need be given either to the presence or the 
absence of motion in this joint. This would make the problem of re- 
duction and immobilization uniform for all fractures of these metacarpals. 

PREREDUCTION REQUISITES 

1. Redudio?i of either overriding or lateral displaceinent must first 
be done. Traction, countertraction, and manipulation, with the entire 
finger in flexion, usually produce the desired effect. 

2. Shoidd the fracture he an impacted one, it is absolutely imperalwe 
that it be broken up. The distal fragment must be freely movable before etther 
correction of the angulation or immobilization is attmnpted. 

REDUCTION AND IMMOBILIZATION 

Since reduction is so intimately associated with the immobilization, 
these two procedures will be discussed together. 

T0E JOURMAC OF BO.VK AX'D JOIXT SURGERY 



FRACTURES OF THE SIETACARPALS 


183 



Fig. 8-A Fig. 8-B 


Case 8. Complete correction of the Case 8. Note the lengthening of 
dorsal angulation by the author’s method, the metacarpal. Compare with Fig. 
following preliminarj^ osteotomy. 7-B. 

Immobilization is done in two stages: 

First Stage 

A strip of heavy piano felt, one inch wide and about ten inches long, 
is split into two equal thicknesses. After one edge of one strip has been 
beveled off, the strip is laid across the dorsum of the hand, just proximal 
to the fracture line, with the unbeveled edge facing the fracture. Since 
all the counterpressure will take place at this point, it is necessary to pad 
this part more heavily. The redundant portion of the felt is cut away. 
One layer of thin, white, tailor’s felt is then applied to the hand, from the 
unbeveled edge of the heavy felt to about three or four inches aboA'e the 
wrist. (See Figure 9-A.) A plaster-of-Paris dressing is next applied to 
this part of the hand, supplemented with a narrow reenforcement, placed 
transversely across the dorsum of the hand and overljdng the heavy felt. 
(See Figure 9-B.) This reenforcement assures the maintenance of the 
counterpressure. The initial plaster dressing fixes the proximal fragment, 
eliminating the factor of motion at the carpometacarpal joint. 

The finger of the involved metacarpal is now fle.xed at the metacarpo- 
phalangeal and proximal interphalangeal joints to an angle of 90 degrees. 
The distal interphalangeal joint is permitted to remain in extension. 
With the finger in this position, the second piece of hea\y felt is placed 
over it, from the unbevcled edge of the heavy felt on the dorsum of 

VOL. XX. XO. 1. JANT.^RV IMS 






184 


S. A. JAHSS 



Fig. 9-A Fig. 9-B Fig. 10-A 


Note position of the 
heavy felt behind the 
knuckles and just distal to 
a fracture of the neck of 
the fifth metacarpal. It 
is held in position by one 
laj’^er of tailor’s felt, which 
extends about four inches 
above the wrist. 


the hand to a point 
just beyond the finger 


First section of the plas- 
ter-of-Paris dressing ap- 
plied. The second piece 
of heavy felt has been 
placed over the flexed 
finger and strapped to the 
plaster dressing. The 
metacarpophalangeal and 
proximal interphalangeal 
joints are in 90 degrees of 
flexion. The distal in- 
terphalangeal joint is in 
full extension. 


tijD. A long adhesive strip holds it in place. 
Second Stage 

One end of a slow-setting plaster-of-Paris 
reenforcement (one-quarter of an inch thick, 


Note how extension of 
the distal fragment is ob- 
tained through the flexed 
finger. The palm of the 
hand is pressing upward 
on the plaster reenforce- 
ment covering the finger 
from its tip to the flexed 
proximal interphalangeal 
joint. Note also that the 
surgeon’s other hand stead- 
ies tlie initial plaster while 
the upward pressure is 
taking place. The posi- 
tion of the two hands re- 
mains the same until the 
reenforcement is incorpo- 
rated in the initial plaster 
and the entire plaster 
dressing is set. 



Plaster-of-Paris dress- 
ing completed. Dorsal 
view. “Free knuckles” per- 
mit extension of other 


Lateral view. The fin- 
ger can be inspected easib". 
Tlic wrist is fixed in about 
5 degrees of extension. 


Finished plaster dress- 
ing. Note freedom of the 
thumb and the other fin- 
gers for flexion. 


fingers. 


THE JOURNAL OF BONE AND JOI.NT SURGERV 







FRACTURES OF THE METACARPALS 


185 


one inch wide, and 
about fourteen inches 
long) is placed on the 
palmar aspect of the 
first plaster, four 
inches proximal to 
its distal edge, along 
the extended distal 
interphalangeal joint 
to the flexed prox- 
imal interphalangeal 
joint. With the palm 
of the hand, gentle up- 
ward or dorsal pres- 
sure is exerted on the 
reenforcement cover- 
ing this part of the 
finger (from its tip to 
the flexed proximal interphalangeal joint), with most of the force at the 
flexed proximal interphalangeal joint, until the dorsal angulation is over- 
come. (See Figure 10-A.) Once this is accomplished, the pressure re- 
mains constant to maintain the correction. An assistant then quickly 
brings the remainder of the reenforcement over the proximal phalanx 
and the knuckle, and, finally, onto the dorsal aspect of the first plaster 
for a distance of about three or four inches. The reenforcement is then 
immediately incorporated in the first plaster with one plaster bandage 
by including only those parts which overlap the first plaster. (See 
Figures 10-B, 11-A, and 11-B.) The dorsal or upward pressure is not 
released until the entire plaster is thoroughly set. 

At times, due to the motion present in the carpometacarpal joint of 
the fifth finger, ulnar deviation of the distal fragment takes place. This 
is easily controlled by extending the transverse dorsal plaster-of-Paris 
reenforcement over the sides of the index and little fingers, following 
manual correction by radial pressure. 

A word of caution is necessary. The second section of the plaster 
should not be applied unless the distal fragment is freely movable. When 
such is the case, verj’’ little force is necessaiy to produce perfect alignment. 
Should this precaution not be taken, then the amount of force neccssar 3 ' 
to correct the angulation is such that a pressure sore will undoubtedh' 
develop over the proximal interphalangeal joint. The development of 
an area of local skin necrosis does not, bj" anj" means, presage a poor 
result. It merelj' prolongs the treatment. 

.\FTER-C.\RE 

Immobilization for two and one-half weeks is usualh' sufficient. 
Massage, local heat, and exercises are indicated. Most important of 
these are the active and jiassive exercises. 

VOI., XX. XO 1. JAN'VAUY lO.'iS 




Fig. 12-A Fig. 12-B 

Fig. 12-A: Before reduction. Upper arrow shows the 
downward thrust exerted by the edge of the initial plaster 
dressing. The lower arrow shows the upward or dorsal 
thrust by the long plaster reenforcement. 

Fig. 12-B: After reduction. Showing correction of the 
dorsal angulation, the resultant action of the two forces. 





186 


S. A. JAHSS 


There is always some fixed flexion present at the metacarpophalan- 
geal and proximal interphalangeal joints when the plaster is removed. 
It is much more pronounced in the latter joint. This is due to periar- 
ticular adhesions, which must be thoroughly broken up. It is the 
author s practice to do this at the time when the plaster is removed. 
When the joints are gently extended by the surgeon at this time, a sudden 
give will be felt soon after the inception of this passive motion. As soon 
as this takes place, full extension is rather easily accomplished. Subse- 
quently, complete passive flexion and extension are carried out daily 
until such time as the patient can actively flex and extend these joints 
within the normal range. Immediately after the first manipulation, the 
patient has no power of extension in the proximal interphalangeal joint. 
The finger hangs limply at this joint and one may become concerned over 
this absence of function. Within one or two days the power of extension 
returns. The patient is instructed to move these joints actively and pas- 
sively many times a day. 

Too much stress cannot be placed on the importance of the after- 
treatment. An excellent result, Avith no restriction of motion, can be 
expected, if diligent and painstaking physiotherapy is carried out. 
Otherwise, some restriction of extension is the rule. This restriction of 
motion, strange to relate, is usually at the proximal interphalangeal 
joint and not at the metacarpophalangeal joint. Why it should affect 
a joint not even close to the fracture, while the joint actually at the 
fracture site remains free, is a phenomenon for which no explanation is 
offered. 

The present series comprises ten cases. Of these, nine were recent 
fractures and one was an old malunited fracture. (See Figures 7-A and 

7- B.) In this last case, an osteotomy through the angulation was done, 
and the case Avas treated as if it AA^ere a recent fracture. (See Figures 

8- A and 8-B.) 

The results in the ten cases haA'-e been uniformly good. 

SUMMAKY 

Fracture of any one of the four inner metacarpals can be reduced by 
upward or dorsal pressure on the flexed distal fragment, AAdth the meta- 
carpophalangeal and proximal interphalangeal joints of the involved 
finger held at 90 degrees of flexion. This position at the metacarpo- 
phalangeal joint relaxes the interosseous muscles and at the same time . 
tenses the collateral ligaments, permitting extension (correction of the 
angulation) of the distal fragment through upAvard or dorsal pressure on 
the flexed proximal interphalangeal joint. This correction can be best 
maintained if the plaster-of-Paris dressing is applied in tAvo sections : the 
fu'st, to immobilize the proximal fragment; and the second, to maintain 
the correction. 

The author wishes to express his thanks to Dr. S. IQeinberg and Dr. H. Lusskin 
who treated Cases 8 and 7 according to his method. 

THE JOURNAL OF BONE AND JOINT SURGEKY 



ADAMANTINOMA OF TIBIA 

Report of a Case * 

BY DONALD J. REHBOCK, M.D., AND C. G. BARBER, M.D., 
CLEVELAND, OHIO 

From the Departments of Pathology and Surgery, 

St. Vincent Charity Hospital, Cleveland 

The adamantinoma, an epithelial tumor long recognized as arising 
in the jaw and in the hypophysis cerebri, is known also to occur in a third 
location, — namely, the tibia. Fischer first described such a tumor of 
the tibia in 1913. Not until 1930 was a second case described by Richter, 
and since then four more cases have been recorded by Baker and Hawks- 
ley, Ryrie, Holden and Gray, and Bishop. It is the purpose of this 
paper to report the clinical and pathological aspects of an additional case. 

CASE REPORT 

R. S., a Jewish housewife of twenty-four years, entered St. Vincent Charity Hospital 
on October 14, 1936, complaining of pain in the left ankle. She had sprained the ankle 



Fig. 1-A Fig. 1-B 

Roentgenograms of left tibia, showing character of bone involvement. 

* Received for publication May 11, 1937. 


VOI.. XX. XO. I, JAXU.MIY IP3S 


1S7 


188 


D. J. REHBOCK AND C. G. BARBER 


eighteen months previously and since that time liad had slowly progressive difficulty in 
walking. 

Examination shoAved an obese woman Avho limped. On the medial aspect of the 
lower third of the left leg there was a rounded, tender, slightly fluctuant, subcutaneous 
mass, approximately six centimeters in diameter. This was flxed to the tibia, but not 
to the skin. The overlying skin was elevated one and five-tenths centimeters above the 
surrounding skin surface, but was not discolored. 

Roentgenograms showed a cavity, four centimeters in length and two and three- 















ADAMANTINOMA OF TIBIA 


189 


tenths centimeters in diameter, situated in the lower third of the tibia with its lower mar- 
gin two and five-tentlis centimeters above the articular surface. The borders of the cavitj' 
were regular and sharply outlined, and there was no reaction in the surrounding bone. 
The cavity had broken through the cortex posteriorly. The periosteum was slightly 
thickened from the internal malleolus upward for eight centimeters over the medial and 
anterior surfaces of the tibia. The lesion was interpreted roentgenographically as a Bro- 
die’s abscess, particularly because of the sharp limitation of the borders of the cavity and 
the inflammatory type of periosteal thickening. 

At operation on October 15, 1936, the presenting portion of the lesion was found to 










TABLE I 

Analysis of Reported Cases of Adamantinoma of the Tibia 


190 


D. J. REHBOCK AND C. G. BARBER 


Result 




Recurrence in 

6 months. 
Amputation. 

Recurrence in 

2 years. 

Recurrence in 
14 months. 
Amputation. 


Operation 

Tibial resection and 
bone graft 

Amputation 

1 

Subperiosteal re- 
section of 4-inch 
segment of bone 

Tumor curetted 
out 

Wide local excision 

Curettage and 
cauterization 

Wide local excision 

Preoperative 

Diagnosis 

1 

Primary tumor 

Myelogenic sar- 
coma 

Myeloma 

Bone sarcoma 

Bone cyst 

Bone cyst or 

giant-cell tumor 

Brodie's abscess 

Duration of 
Symptoms 
Prior to 
' Operation 

5 months 

8 months 

6 weeks 

16 years 

8 years 

2 years 

3 years 

18 months 

Symptoms 

Pain and 
swelling 

Swelling 

Pain 

Pain and 
tenderness 
Swelling 

Pain 

Swelling 

Pain i 

<D 

Left tibia 

Left tibia, 
middle 
third 

Left tibia, 
lower third 

O' 

Left tibia, | 
lower third 

Right tibia, 
upper 
third 

Left tibia, 
lower third 

Sex 

Male 

Male 

Male 

Male 

Female 

i 

Male 

Female 

Age 

(Fears) 

37 

12 

46 

44 

36 

22 

24 

Author and 
Year 

Fischer (1913) 


Richter (1930) 

Baker and 
Hawksley 
(1930) 

Ryvie (1932) 

Holden and 
Gray (1934) 

Bishop 

(1937) 

Rehbock and 
Barber 
(1937) 

a 








CO 

c3 

T— ( 

CN 

CO 


iO 

O 


o 









THE JOURNAL OF BONK AND JOINT SURGKR'' 



ADAMANTINOMA OF TIBIA 


191 


have a thick fibrous capsule which fused with the adjacent tendons and muscle. Incision 
through the capsule showed one large eavity and several small eavities filled with a thin, 
clear, straw-colored fluid. The outer wall of the mass contained no bone and it was 
removed for pathological examination. On October 20, 1936, the involved tissues were 
widely excised, leaxdng a narrow bridge of healthy tibial shaft. The woimd healed 
rapidl 3 ', and the patient was discharged in eleven days, wearing a cast. Subsequent 
roentgenograms of the skull showed no evidence of tumor in the jaws or pituitary fossa. 
On June 19, 1937, eight months after operation, there was no roentgenographic evidence 
of tumor recurrence in the leg. 

Pathological Examination: The biops}' specimen on October 15, 1936 consisted of a 
single piece of firm, pale tissue, measuring three and five-tenths bj' two and five-tenths 
centimeters bj' one centimeter. This was covered over one surface by a fibrous mem- 
brane representing the external capsule of the tumor. The tissue was dense, firm, and 
tough, but contained no cartilage or bone. The specimen removed on October 20, 1936 
consisted of sixty grams of fragmented bone and soft tissue. 

Microscopic examination showed dense fibrous connective tissue, throughout which 
were irregiflarly disposed epithelial masses. In some situations these epithelial masses 
were characterized by a peripheral single layer of small cuboidal cells, followed within 
by flat or polj’gonal cells. More centrally, these masses showed hj'dropic infiltration 
mth nets of polygonal, stellate, or branching cells. Cj'stic spaces were present in some 
areas. There were epithelial pearls with and without keratinization, some showing 
calcification. In many areas compact epithelial cells without architectural arrangement 
were disposed without sharp demarcation from the fibrous stroma. The bone adjacent 
to the soft tissue tumor showed degeneration of bony trabeculae, fibrosis of marrow 
spaces, and irregular penetration by the tumor for a short distance. 

COMJIENT 

That a tumor producing the essential features of the enamel organ 
should occur as a primary tumor in the lower third of the tibia seems 
bizarre. Malassez’s theory as to the origin of the adamantinoma of the 
jaw is acceptable, as is pointed out by McFarland and Patterson in their 
thorough review of the subject of adamantinomata. According to this 
theory, the tumor in the jaw arises from atrophic or isolated groups of 
epithelial cells about the roots of the teeth. The adamantinoma of the 
hypophysis originates in epithelial remnants of the hypophyseal duct. 
The origin of this tumor of the tibia, however, is less clearly explained. 
Fischer assumed that it originated from a foetal cell rest formed during 
the intra-uterine period. Baker and Hawkslej’- followed Fischer in 
postulating a foetal epithelial rest, but laid some stress on trauma as 
stimulating the rest into growth. Ryrie also emphasized the etiological 
importance of trauma, but believed that the growth arose from epithelium 
implanted at the time of injurj’’. 

There is no doubt concerning the identitj’^ of those tumors with those 
of the jaw and the hypoidiysis. As was pointed out by Duffy, adaman- 
tinomata of whatever location produce a structure wliich tends to repro- 
duce the essential features of the enamel organ. Tlie columnar peripheral 
laj'or of the neoplastic epithelial proces.=es corresponds witli the so-called 
‘‘inner layer” (of adamantoblasts) of the enamel organ, the subcolumnar 
transitional zone of vesicular epithelial cells with the “intermediate 
zone,” and the reticulated hydropic central zone of stellate epithelial 

voi,. XX. xo. I. JAXU.\nv ipss 



F. L. BUTTE 



TENDON TRANSPOSITION 


An End-Restjlt Study * 

BY CHARLES TV. PEABODY, M.D., DETROIT, MICHIGAN 

From the Detroit Orthopaedic Clinic and the Orthopaedic Division 
of the Children’s Hospital of Michigan 

INTRODUCTION 

In presenting this paper, the writer assumes at the outset that it 
would, to the majority of orthopaedic surgeons, be unnecessary and 
superfluous to demonstrate the proposition that tendons or muscles can 
be transposed to a new site and function in a new direction, even though 
this elementary fact may not have unanimous recognition. 

On the other hand, the writer, from his own clinical experience plus 
observations of this phase of surgery in many different localities over a 
period of nearly twenty years, is very definitely of the conviction that a 
wider application and a more satisfactory achievement in the ultimate 
functional result would obtain through appreciation and acceptance of 
certain precise and standardizable indications for the utilization of this 
type of surgery. It is his impression that the modern orthopaedic surgeon 
with good basic surgical technique and understanding of the principles of 
tissue physiology and healing, established long ago by Lange, Biesalski, 
and Mayer, can quite uniformly produce a functioning tendon trans- 
plant. That the procedure has been too often disappointing to patient 
and surgeon in its ultimate benefit and has as a result a minority of en- 
thusiastic adherents is due, the writer believes, to an inadequate recogni- 
tion and appreciation of the part played by certain physical principles 
in the selection and indications for the procedure. Its greatest field is, of 
course, the disabilities residual from anterior poliomyelitis; yet the une- 
qual distribution of this disease restricts the practical experience of surgi- 
cal rehabilitation to a comparatively few surgeons. At the same time, 
while much has been written relative to the technique and results of 
certain specific operative procedures, there is little or nothing of impor- 
tance on the phase of selection and indications, and particularly on the 
physical factors involved, in our literature (textual or current) since the 
early work of Lovett. 

The possibility of a somewhat authoritative contribution on this 
subject arises from a body of clinical material under the writer’s control 
during the last ten years which has provided opportunity for about 300 
operations for tendon transposition, 240 of which were performed more 
than three years ago. Of these 240 patients, 215 were examined for 
results after such an interval. As to the question of obtaining a working 

* Presented before the Atncrican Academy of Orthopaedic SurRoons, Cievdand, 
Ohio, January 12, 1937. 


VOl.. XX. NO. 1. JAXCAUY tOSS 


39.3 



192 


D. J. REHBOCK AND C. G, BARBER 


cells with the enamel pulp or middle zone of the enamel organ. The 
slow rate of growth, cystic degeneration, tendency to recur after local 
excision, and failure to metastasize are characteristic of these tumors 
whether in the jaw, the pituitary body, or the tibia. 

The diagnosis of adamantinoma of the tibia can be made only by 
histological examination. However, the characteristic location, the his- 
tory of trauma followed by a latent period and then by pain, and a roent- 
genographic picture of a sharply outlined area of bone destruction should 
lead one to consider the possibility of adamantinoma. Once the diagnosis 
is established by biopsy, the operation of choice is resection of the shaft 
of the tibia, followed by a bone graft. In doing the resection one should 
keep well above and below the tumor area. Local resection of the tumor 
with the chisel and curette in three of the previously reported cases was 
found to be inadequate. 

Grateful acknowledgment is made to Dr. Francis Carter Wood for the photomicro- 
graphs which accompany this case report. 

REFERENCES 

Baker, A. H., and Hawksley, L. M.: A Case of Primary Adamantinoma of the Tibia. 
British J. Surg., XVIII, 415, 1930-1931. 

Bishop, E. L.: Adamantinoma of the Tibia. Southern Med. J., XXX, 571, 1937. 
Duffy, W. C.: Hj’^pophyseal Duct Tumors. Ann. Surg., LXXII, 537, 725; 1920. 
Fischer, Bernh. : Ueber ein primares Adamantinom der Tibia. Frankfurter Ztschr. 
f. Path., XII, 422, 1913. 

Holden, Edgar, Jr., and Gray', J. W.: Adamantinoma of the Tibia. J. Bone and Joint 
Sui'g., XVI, 401, Apr. 1934. 

Malassez, L.: Sur le r61e des debris epithcliaux paradentaires. Arch, de Physiol. 
Norm, et Path., V, 309; VI, 379; 1885. 

McFarland, Joseph, and Patterson, H. M.: Adamantinomata. A Review of One 
Hundred and Ninety-Six Cases Reported in the Medical and Dental Literature. 
Dental Cosmos, LXXIII, 656, 1931. 

Richter, C. S. : Ein Fall von adamantiiiomartiger Geschwulst des Schienbeins. Ztschr. 
f. Krebsforschung, XXXII, 273, 1930. 

Ry’rie, B. j. : Adamantinoma of the Tibia: Aetiology and Pathogenesis. British Med. 
J., II, 1000, 1932. 


the journal of bone 


and joint SURGER'’ 



TENDON TRANSPOSITION 


195 


cation for combining the two ts'^pes of procedure at one operation if the 
age is appropriate. The second postulate is that, for essentially static 
deformity, tendon transposition as a rule will not suffice, and joint fusion 
will be necessarj"^; but, in contrast to dynamic deformity, static deformity 
is easilj’’ susceptible of mechanical control during the period prior to the 
applicabilitj’- of bony stabilization. Thus, procedures of tendon trans- 
position may be undertaken with one of three distinct aims; (1) purely to 
re.store a lost functional capacity, mainly applicable to the ujiper extrem- 
ity; (2) to remedy a positive or dynamic imbalance by a balanced redistri- 
bution; and (3) to remedj’- a static imbalance by tendon transfer alone 
(biceps transposition 
at the knee). 

The second kej'^ 
consideration is the 
evaluation of the mus- 
cle which suggests 
itself for tendon 
transpo.sition, both as 
to its state of efficiency 
and as to its physio- 
logical adaptabilitJ^ 

At the outset, 
it should be stated 
that the necessitj’" of 
complete reversal to 
an opposite function 
is no contra-indica- 
tion to selection; re- 
education nia}’^ be 
slower, but, if other 
principles are ob- 
served, an effective reversal of function can be expected. On the other 
hand, anj;- degree of paresis or weakening is a contra-indication if the pri- 
mary purpose of the transposition is to replace a wiped-out muscle or group 
of muscles. A subnormal muscle may still be selected for transfer when it is 
a factor in djmamic instability if this is the primary consideration, or when 
its transfer places it in combination with anotlier only .slightlj^ subnormal 
but inadequate muscle or group. Finally, its ph 3 \siological action must be 
con.sidered. A short-bellied, short-excursion, stead 3 '’-pull muscle is not 
adapted to replace the opposite — that is, the strap-t 3 ’pe, long-excursion, 
light-load muscle — and vice versa. It should, of course, go without .sa 3 dng 
that accurate testing and rating of all muscle groups of the affected part 
arc c.sscntial for ain’ proper evaluation of the presenting situation and the 
possibilities for its relief. In the anah'sis of the clinical material which 
has led to the establishment of specifie indications, a grouping into five 
basicalh' different t3q5es of imbalance has been done. 



Fig. 1-A Fig. 1-B 


Fig. 1-A; T 3 ’picaJ earJj* diagnostic complex of isolated 
weakness of tibialis anterior. On dorsal-e.'^tension effort, 
the foot goes into the clawed position and remains in 
plantar fle.xion; on weight-bearing, the foot is in planovalgus. 

Fig. 1-B; Balanced control after proximal transposition 
of extensor hallucis longus. 


VOL. XX, XO. I. JAXCAnV IMS 



194 


C. W. PEABODY 


or functioning muscle after transposition, some jmstoperative observa- 
tions prevail on the entire 300, with positive findings in 92 per cent. Of 
the 215 patients checked up at periods of from three to ten years after 
operation, a strongly working transplant was observed in 90 per cent. Of 
the total cases, a considerable number represented a variety of types of 
paralytic residuals, of which no one group was sufficiently large to war- 
rant dogmatic conclusions; but there remained several diff.erent situa- 
tions in which the experience seemed adequate to make quite positive 
predictions as to indications and results. 

DISCUSSION 

Inasmuch as in this study sufficient!}'' extensive evidence from the 
statistical angle is limited to work on the lower extremities, discussion 
will be restricted to this phase. However, it is here that what the author 
regards as the key considerations are most particular!}'- involved. The 
foremost of these is the necessity of determining to wdiat degree the dis- 
ability or deformity is static (negative) and to what degree it is dynamic 
(positive). The mo.st obi'ious example of dynamic deformity is the cal- 
caneus foot; of static deformity, that jilanovalgus foot which, more or 
less flail, is without any power in the invertors. In the former instance, 
no amount or extent of arthrodesis alone will prevent in the growing 
child a recurrence of deformity. In the latter instance, fusion and block 
procedures readily eliminate all further concern about deformity. 

Other situations are not so simple, and we must realize that dynamic 
instability is always present to some degree whenever the antagonists of 
any weakened muscle group are strongly active. For instance, when the 
invertors of a foot are inadequate to static stress, the planovalgus de- 
formity will include a static element, but, if the peroneal group is strongly 
active, a dynamic element is added, which, if overlooked, ivill spoil the 
result of any arthrodesis. While the drop-foot equinus element of the flail 
foot is a negative or static one, it is not difficult to control by corset shoe, 
brace, tenosuspension, or bone block. On the other hand, the equinus 
element of a foot with impaired dorsiflexors and strong plantar flexors tends 
to overcome any measures of control as long as the dynamic imbalance 
of unopposed calf-muscle groups remains. 

Accordingly, we can establish two primary postulates. The first is 
that essentially dynamic imbalance is an imperative indication for 
“redistribution”, a reconstructive procedure, w'ith experience showing 
that transposition can be so adapted as to restore both balance and ade- 
quate function, often without necessity for sacrifice of normal mobility. 
The indication has no limitation to any age period, for, even if entirely 
complete stability may not in certain situations obtain from redistribu- 
tion alone, deformity becomes easily preventable by minimal suppoit 
until an appropriate age for some limited joint fusion is reached. hen an 
imperative indication for redistribution by tendon transposition is also 
accompanied by additional need for joint fusion, there is no contia-in i 

THE JOURNAL OF BONE AND JOINT SURGERl 



TENDON TRANSPOSITION 


197 


flexion were satisfactory in all. In the other type, when the planovalgus 
was moderate and easily correctable, this tendon transposition alone gave 
a high percentage of satisfactorj’’ results, both as to statics and to extensor 
function. In the presence of .severely relaxed or fixed planovalgus, an 
astragalonavicular az-throdesis was combined with the tendon transposition. 

The whole series of forty-three cases were anal 5 ’'zed from the stand- 
point of (1) extensor function and (2) posture. In regard to the formei’, 
adequate function prevailed in thirty-four, was improved in eight, and 
was unchanged in one. Restudy of the last case indicated an original 
rating of some impairment of the extensor hallucis longus which, in the 
absence of an active tibialis anterior, should have ruled this case out of 
this group. In all instances but one, those cases in which function was 
improved but not adequate had presented with a recurrent equinus after 
lengthening of the Achilles tendon done elsewhere. In this whole group, 
contracture of the Achilles tendon was overcome before operation when 
possible by gradual stretching, and the only cases in which it was not 
possible and in which tenotomy was required were those of prior lengthen- 
ing of the Achilles tendon. In respect to posture, twenty-nine patients 
had good posture; nine, fair; and five, poor (pronation). Analj’-sis of 
these last five cases revealed two in which an overlooked impairment 



Fig. 3-A Fig. 3-B 


Complete loss of dorsal extensors with weakness of invertors. 

Fig. 3-.^: Function before operation. 

Fip. 3-B; Funetion after forward transfer of both pcronci. No arthrodesis 
was done. Note neutnal posture of foot. 

VOI.. ,N-o. I. JANT.^RY ia.1S 





196 


C. AV. PEABODY 


GROUP I — LIMITED EXTENSOR-INVERTOR INSUFFICIENCY 

Forty-three case.s arc availalile in whicli a specific transposition was 
done for this precise type of residual imbalance; consisting of isolated 
paralysis or notable weakness of the tibialis anterior muscle. The func- 
tional defect liere is often not apparent early, and deformity is often 
sloivly progressive. The reliable diagtio.stic complex is a foot in which 
the effort at dorsiflexion is found to be inadequate with the toes retracting 
and the foot going into cavus as the effort is made, and in which either per- 
manent equinus or limitation of passive dorsiflexion prevails (idiopathic 
claw-foot being ruled out by the finding of absent or weak effort in the 
tibialis anterior). As a rule, on iveight-bearing these feet take a plano- 
valgus position, but this group includes some cases ivhich shoived no pro- 
nation but did have contracture of plantar fascia and moderate cavus. 
From the angle of muscle-testing, the author has found no explanation of 
these two different types. Compensation or substitution for the tibialis- 
anterior inadequacy of course takes place by excessive effort ivith the com- 
mon digital extensor and with the proper extensor of the big toe. The 
writer’s impression is that the indiiddual who strives as long as possible 
to improAm this substitution by fixing the toes with their flexor mechanism 
develops a straight equinus vdth cavus; in the others the foot assumes the 
position of planovalgus. In both positions there prevail elements of 
both static and dynamic imbalance. 

In all forty-three cases, restoration rvas attempted by transposition 
of the tendon of the strong extensor hallucis longus from its relatively 
ineffective insertion in the toe to one in the foot itself, usually at the base 
of the first metatarsal. Saim for plantar fasciotomy, nothing else was 
included in the operation in the cavus type, and both posture and dorsi- 



Fig. 2-A Fig. 2-B Fig. 2-C 


Complete loss of both tibials, and marked toe-extensor weakness. 

Fig. 2-A: Extreme dynamic planovalgus, associated with drop-foot. 

Figs. 2-B and 2-C; After operation for forward transposition of both peronci plus 
Hoke reconstruction of skeletal deformit 5 \ 


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TENDON TRANSPOSITION 


199 


ment; however, in 
about half of these 
cases this procedure 
was necessaiy. Poor 
statics resulted after 
operation in onl}^ one 
of the twenty cases. 

TjToe-B cases were 
those showing severe 
impairment of both 
tibials, as well as of 
the toe extensors, and 
transposition of both 
peronei to the dorsum 
of the foot was done 
in thirty-four cases. 

Adequate extensor 
function prevailed in 
thirty-two. Study of 
the two failures showed 
that in one case trans- 
position of a peroneal 
group definitely rated 
as weak had been done, 
and in the other in- 
fection had occurred. 

As would be expected, 
preoperative structural 
deformity was severe 
in the long-standing 
cases, necessitating the 
Hoke procedure at the 
time of transposition 
in twenty-three cases, all of which on check-up showed satisfactory 
statics. In eleven cases, the transposition was done at an age prior to 
the apiilicability of arthrodesis, but on check-up none of these showed 
inadequate lateral stabilitj’’, with posture or statics excellent in eight. 
The writer believes that, if in these earlj”- cases the patients continue to 
wear ankle-high shoes until maturity, arthrodesis for lateral instabilit3' will 
not be necessarj\ 

In summarj' of Group II (one or both peronei forward), adequate 
functional control prevailed in fiftj'-one out of a total of fift\’-four cases, 
with satisfactoiy statics in fiftj'-three; some tj'pc of fusion iirocedure was 
added in thirtj'-four. Group II must be considered as being composed 
mainlj’- of cases of dj'namic imbalance, the jjrcscnting pattern being 
equinovalgus from residual extensor-invertor ])arah"sis. 



Fig. 5 

Anterior and posterior views before and after outward 
transposition of tibialis anterior tendon for varus instabil- 
ity due to peroneal insufficienev. 


VOL. X.X. XO. 1. J.<NC.\UY IPSS 




198 


C. W. PEABODY 


of the^ tibialis posterior prevailed, and three in which a fusion failed to 
consolidate, having been done at too early an age. 

Accordingly, we have a partly dynamic and partly static situation, in 
which subtraction from the dynamic side is not necessary, and in which 
balance and stability can be restored cither by transposition alone of the 
extensor hallucis longus or b}'- a combination of this procedure with as- 
tragalona'idcular arthi’odesis according to the prevailing conditions, the 
presenting pattern being an extensor-invertor insufficiency from residuals 
limited to the tibialis anterior muscle. 


GROUP II — GROSS EXTENSOR-INVERTOR INSUFFICIENCY 

There were fifty-four cases which fell into this classification by 
leason of their haidng notable impairment of the toe e.xtensor muscula- 
ture in addition to impairment of the tibials. The appropriate indications 

for tendon transposition required further subdi- 
vision into two types, A and B. 

Type-A cases showed extensor inadequacy 

of drop-foot equinoval- 
gus character, due to 
weakness or paralysis 
both of the toe exten- 
sors and of the tibialis 
anterior, but without 
more than one-grade 
weakness of the tibi- 
alis posterior, the rest 
of the musculature be- 
ing normal. In this 
type of imbalance, if 
redistribution is done 
relatively early, there 
is required nothing 
more than transposi- 
tion of the peroneus 
longus ' to the dorsum 
of the foot. Quite a 
long time ago the author discontinued the technique of transposition 
completely across into the sheath and the insertion of the tibialis anterior, 
because, although very adequate dorsiflexion uniformly followed, it some- 
times reversed the invertor-evertor imbalance and left the foot unstable 
in varus, a condition which was found to be obviated by locating the 
insertion of the transplant at the dorsal aspect of the mesial cuneiform. 
Transposition was done in twenty cases, in nineteen of which adequate 
restoration of extensor control resulted. Arthrodesis, usually astragalo- 
navicular, was done only in those cases in which prior to operation deform- 
ity had continued until structural changes prevented satisfactory realign- 

THK JOUUNAT^ OF BONE AND JOINT Sl’nOEH\ 



Fig. 4-A 


Fig. 4-B 


Fig. 4-A: Complete drop-foot and beginning cavus result- 
ant from extensive dorsifiexor insufficiency (incomplete for 
toe ex'tensors). 

Fig. 4-B: Active dorsifiexor capacity in stable foot five 
years after forward transposition of peroneus longus. No 
arthrodesis was done. 





Fig. 2 

Case 1. Pelvic-tilt examination. Patient sitting with left side of pelvis elevated. 


VOL. XX. XO. 1, JANUARY 1H3S 


200 


C. W. PEABODY 


GROUP III EVERTOR INSUFFICIENCY 

Compared with the other groups, this was a small one, there being 
only eleven cases. In the earlier years covered by this study, bony 
stabilization alone was apiilied to this type of imbalance— namely, loss 
of power of the peronei, with musculature otherwise normal — but recur- 
rent varus deformities brought the realization that redistribution should 
be attempted in this pattern also. The operative procedure in the eleven 
cases consisted of lateral transposition of either the extensor hallucis 
longus or the tibialis anterior. If the situation showed a slight peroneal 
impairment, or moderate impairment plus slight weakness of the tibialis 
posterior, the extensor hallucis longus was transposed to the base of the 
fifth metatarsal. In instances of greater impairment, the tibialis anterior 
was transposed to the cuboid and the extensor hallucis longus to the first 
metatarsal. Balanced extensor function prevailed in all cases; stability 
and posture were good in seven, fair in three, and poor in one. This 
particular group was made up entii’ely of fairly young children and no 
bony stabilization was added. When a complete loss of power of the 
peronei prevails, and a normal tibialis posterior persists, greater security 
against varus imbalance can be obtained by adding tenotomy of this tibial. 
Long-standing varus instability with advanced deformity will always 
require the addition of the Hoke procedure, but instability at the ankle 
joint will eventually develop if this method alone is relied upon. The 
condition must be regarded as a purely dynamic instability. 

GROUP IV — TRICEPS SURAE (tENDO ACHILLIS) INSUFFICIENCY 

The author suspects that all orthopaedic surgeons will regard the 
dynamic calcaneus foot as the most grievous of all types of muscle imbal- 
ance, both in the disturbance of gait, the deforming tendencies, and the 
difficulty of control; and that they also will agree that a foot free from 
deformity with a pan-arthrodesis in slight equinus position is vastly 
preferable to calcaneus instability. However, if this imbalance occurs in 
a small child before the age when such a type of arthrodesis is feasible, the 
writer does not believe that any appliance will prevent the development of 
severe deformity. When this deformity is corrected by the necessary 
bone resections, a badly maimed foot results. The author has seen too 
many recurrent calcaneus or calcaneocavus deformities after bony pro- 
cedures done before maturity to have much faith that any such proceduie 
alone can be permanently successful in the face of persistent dynamic 
imbalance. As far as the age of applicability is concerned, the same argu- 
ment prevails for control by Achilles tenodesis. 

On- the other hand, the writer is convinced that apiiropriate ledis- 
tribution at an early post-paralytic stage (two to three years) will pi event 
progressive deformity, but at this point he wishes to state that the on y 
redistribution which he has found to restore completely a lieel-and-toc 
gait and tiptoe capacity is the transposition of the tibialis anterior tin oug i 
the Achilles tendon to the os calcis. However, his experience with t ns 

THE JOURN'AL OF BONE AND JOINT SOBOnBI 



TENDON TRANSPOSITION 


201 


procedure has been limited to eight cases, only half of which have passed 
the three-year period. Although so far it has proved satisfactory in 
restoration of tiptoe function, a more perfect balance might be secured 
by the additional transposition of the extensor hallucis longus, when this 
muscle is competent, to the dorsum of the foot. 

The observations on this imbalance seem to indicate that a pure 
calcaneus deformity will result in a condition in which all muscle action 
is practically absent except that of the dorsal extensors. Isolated 
paralysis of the triceps surae muscle is regularly followed by a calcaneo- 
cavus deformity, a more dangerous one than a pure calcaneus deformity. 
Insufficiency of the Achilles group, combined with lateral imbalance, 
adds an element either of varus or of valgus instability. 

Leaving aside the eight transpositions already mentioned, there were 
found available for analysis forty-five transposition operations for some 
type of calcaneus imbalance, which were subdivided into three groups. 
Inasmuch as in few cases were the patients able to walk on tiptoe after 
the procedure, the degree of restored balance was rated as follows; “ade- 
quate” when a semblance of heel-and-toe action prevailed and the plan- 
tar flexor power was as good or greater than that of the dorsal extensors; 
“improved” when these conditions were not obtained, but enough power 
was restored to prevent recurrence of the calcaneus; “failure” when the 
calcaneus imbalance recurred. The operation did not include any bone 
surgery in about one-third of the cases. 

Type A included twenty-six cases in which the invertors also were 
impaired, with a calcaneovalgus imbalance from the normal peronei, the 



Fig. 0 


After transposition of peronei to licel for calcaneus imbalance and weak in- 
vertors, sliowinp result in active dorsiflexion, active plantar flexion, and tiptoe 
position. No .stabilization was done. 


VOI.. XX, NO. 1. JAXUAUY It>ZS 




202 


C. W. PEABODY 


latter being transposed to the os calcis. Results from the standpoint of 
function were: adequate, sixteen cases; improved, ten cases. The rating 
of statics and stability was as follows: of nineteen patients with tarsal 
fusion, the results were good in sixteen and fair in three; of seven without 
fusion (operation at an early age), the results were good in four and fair in 
three. 

Type B represented eight cases with a combined varus imbalance 
from weak peronei, and transposition of the tibialis posterior, as well as of 
the flexor hallucis longus, was done. Results in respect to function were: 
adequate in five; improved in two; and failure in one. Posture and 
stability were good in all cases, but in all either tarsal arthrode.sis was 
done to correct deformity or backward displacement of the tarsus was 
done to obtain greater leverage. 

Type C, usually calcaneocavus deformity, numbered eleven cases. 
Since the secondary element of deformity was due to the presence both of 
strong invertors and evertors, the peronei and the tibialis posterior were 



Fig. 7 


Calcaneus imbalance from complete loss of all muscles e.xcepttlm^ 
sors; active and passive range before operation; active and passive ra g ‘ 
capacity several years after transposition to heel of tibialis anterioi tend . 
arthrodesis was done. 


THE JOURNAL OF 


bone and joint surgery 




TENDON TRANSPOSITION 


203 


transposed to the os calcis. Function was rated as adequate in seven 
cases and improved in four. Although in one of the former there was the 
nearest approach to tiptoe capacity of all, especial analysis seemed indi- 
cated from the fact that the functional capacity of this group of eleven, 
with double transfers, proved no better in rating than either of the two 
single-transfer groups. Study of this group brought out the fact that in 
the greater proportion of the cases advanced skeletal deformity was pres- 
ent, and, in spite of bony reconstructions, normal leverage was on the 
whole more difficult to obtain; thus, the increased power given by the 
double redistribution was offset. Skeletal reconstruction was necessary 
in eight cases with resultant good statics and stability in all. Bone 
surgery was omitted in three early cases; lateral stability and posture 
were found to be good in two and fair in one. Going back to 
the group of eight cases with apparently ideal results from posterior 
transposition of the tibialis anterior, it should be noted that in that 
series skeletal distortion had not developed, and no bone surgery was 
done. 

Of the total forty-five cases of calcaneus imbalance in which trans- 
positions of lateral muscles were done, adequate function was obtained 
in tiventy-eight; improved function, in sixteen; and failure, in one. In 
consequence of these results, the author’s present recommendations in 
calcaneus insufficiency are as follows: (1) In early cases without skeletal 
distortion, presenting weakness in the Achilles group only, do posterior 
transposition of the tibialis anterior without any bone surgery; (2) in 
early cases with complicating lateral imbalance, transpose the acting 
invertors or evertors, as the case may be; (3) in late cases with skeletal dis- 
tortion but with muscle status as in (2), add necessary tarsal-joint resec- 
tions; (4) in late cases with muscle status as in (1), combine tarsal recon- 
struction with posterior transposition of the peroneus longus and the tibi- 



Fio. S-.\ Fig. S-B 


Fip. S-.A: Qimdriccps p.iraly.^is, sliowing inaliilify to c.vtpiid knee apain.«t pravity. 
Fip. S-B: Capacity apainsf re.'i-=tanrp sevend years after transposition of liieefx 
to patella. 


VOI,. XX. XO. I, JANOAHY I'.l.lS 




204 


C. W. PEABODY 


alis posterior. This is quite feasible as a single operation, but the com- 
bination of tarsal reconstruction and posterior transposition of the tibialis 
anterior is more than should be attempted at one operation. Further- 
more, while the tibialis anterior is the only strong leg muscle with a long- 
range action comparable to that of the triceps surae, extensive tarsal 
reconstruction is, the writer believes, certain to leave too much restric- 
tion of motion to permit tiptoe action even with muscle power adequate 
for it. 


GROUP v — QUADRICEPS INSUFFICIENCY 

There were found in this review eighteen cases of quadriceps insuffi- 
ciency with hamstrings available for transposition. Except in cases of 
fixed knee-flexion deformity, quadriceps insufficiency is an example of 
straight static instability, and an exception to the general rule that this 
instability is not eradicable by tendon transposition alone. However, if 
transposition is done before adolescence, protection by brace against genu 
recurvatum may be necessary, according to hamstring status. In most 
of the cases of this series, simiile forward transfer of the biceps was per- 
formed, but in a few vutli slightly subnormal biceps both inner and outer 
hamstrings were used. Of the eighteen cases, restoration of approxi- 
mately normal' control was secured in eleven and control adequate for 
stability in six; failure resulted in one. 

MISCELLANEOUS TRANSPOSITIONS 

Of the residual operations in the total reviewed, quite a few were in 
the upper extremity with transpositions at elbow and wrist, giving very 
satisfactory results, although not involving the special principles which 
this presentation was designed to emphasize. There remain a few cases 
of involvement of the lower extremity which may be mentioned briefly. 
Six patients received Legg’s operation of transposition of the tensor fas- 
ciae femoris for gluteus-medius paralysis, with results inadequate to rec- 
ommend the procedure particularly, and, to the author, illustrating the 
general rule of inapplicability of transposition of a dissimilar muscle in 
pure static imbalance. Yet, when this same muscle was utilized in the 
prime example of exception to this rule — that is, transposition of the ten- 
sor fasciae femoris to the patella for quadriceps insufficiency in three 
out of six cases a functionally stable knee resulted. The three failures 
occurred where quadriceps paralysis wms complete, while in the success- 
ful cases some quadriceps function (though inadequate) had remained. 
Still under observation are four other cases representing mainly static 
imbalance, — namely, isolated paralysis of the tibialis posterior, in which 
by the operative technique of von Baeyer the peroneus longus was trans- 
posed across the back of the ankle to the inner side of the foot. The 
result to date has been complete restoration of both function and statics, 
so that it may be a useful procedure for this probably rare residual im 
balance. 


THE JOURNAL OF BONE AND JOINT SUROERI 



TENDON TRANSPOSITION 


205 


SUMMARY AND CONCLUSIONS 

About ten years ago, the writer arrived at a stage in the joractice of 
surgical relief of paralytic residual imbalance in which the application of 
certain physical and kinetic principles seemed logically to point to fairly 
precise indications for selection and utilization of muscle and tendon trans- 
ference in a given presenting situation of paralytic residuals. Since then, 
300 operations have been performed udth these principles in mind, and it 
has been possible to check up on the results three or more years after 
operation in 215 of these cases. The results have been analyzed accord- 
ing to function and statics, with conclusions and indications derived from 
the findings in five of the most common and sharply defined situations. 
Tendon transposition has proved to be a most useful procedure in restora- 
tion of lost function, and frequently an imperative procedure in the pre- 
vention and control of imbalance deformity. Its utilization diminishes 
the frequency and the extent of stiffening procedures, sometimes as an 
adjunct to them and sometimes as a preferable substitute for them. Its 
success is as much dependent on the meticulous evaluation of the present- 
ing static, dynamic, and kinetic conditions as on the technique of the 
operative procedure. 


VOL. XX. NO. 1, JANUARY 1935 



SKELETAL TRACTION IN FRACTURES OF THE RADIUS 

AND THE ULNA 

BY EUGENE L. JEWETT, M.D., ORLANDO, FLORIDA 


The nietliocl of obtaining skeletal traction which the writer wishes to 
present is not new, but a few of its features have not been described before 



Fig. 1 

Showing oblique displaced fracture 
of lower ends of left radius and ulna 
with Kirschner wire through the distal 
fragments and traction screws in the 
distal ends of the upper fragments. 
The Kirschner wire tlirough the 
olecranon process is not shown. 


as far as he has been able to determine. 

A fifteen-year-old boy sustained a 
fracture of both bones of the left fore- 
arm a little above the wrist joint. His 
doctor made two unsuccessful attempts 
at closed reduction. The writer then 
tried reduction by the closed method. 
Felt pads were placed in the anterior 
and posterior interosseous spaces to 
separate the fragments, and molded 
plaster-of-Paris splints were carried 
from the fingers to the shoulder with 
the elbow at a right angle. Even 
though the fragments Avere in good po- 
sition after reduction, they slipped by 
each other in a few days. Open opera- 
tion was advised, but the family ivere 
very much opposed to it. Therefore, 
the following method Avas eA’’olA'’ed, 
Avhich proved to be highly successful. 




Fig. 2 

Fragments in the adequate^ reduced 
position with the plaster-of-Paris cast 
applied and tongue-depressor strips 
holding the screw heads from the hard- 
ened plaster cast. 

206 


Fig. 3 

Outer laA'^er of plaster cast coi^ering 
tlie screw lieads and the Kirschncr-wire 
retainers, thereby firmlj' anchoring .aJl 
of the fragments in the plaster cast oy 
means of skeletal fixation. 

THE JOURNAL OF BONE AND JOINT SURGERY 




FRACTURES OF THE RADIUS AND ULNA 


207 


Under general anaesthesia, Kirschner wires were placed through the 
olecranon process and the lower radial and ulnar fragments. (See Figure 
1.) The arm was suspended in a fracture frame. Then drill holes were 
made in the lower end of the upper fragments, as shown in the roentgeno- 
gram. Screws, made especially for this purpose, M'ere inserted into the 
drill holes. Care was taken not to split the bone, but yet to obtain a 
sufficient!}'' firm hold to give the desired traction. Then, by separating 
the two Kirschner wires, the desired extension was secured. When the 
fragments came into line, strong outward traction was applied on the two 
screws, which resulted in the reposition of the fragments into normal 
alignment. Repeated roentgenograms indicated when the reduction was 
satisfactory. A non-padded plaster-of-P'aris cast was then applied from 
the fingers to the mid-arm, incorporating the wires and the screws. Pieces 
of tongue depressor were snugly placed between the hardened cast and the 
washers and heads of the screws, so as to prevent any recurrence of the 
displacement. (See Figure 2.) Plaster was then applied to cover the 
ends of the screws and the Kirschner-wire retainers (Fig. 3). The wires, 
of course, were not taken out of the fracture frame until the retainers were 
secure^ locked in the hardened plaster. Check-up roentgenograms 
showed good position of the fragments, and there was free motion of the 
fingers. 

This plaster cast was cut down to the elbow at the end of eight weeks, 



Fig. 4 

Four ami onolialf montlis after reduction. Clinically and roentgeno- 
graphically the results arc excellent. 


VOI.. XX, XO. 1, J,\XT'.\nY is-is 



208 


E. L. JEWETT 



Fig. 5 


Fracture frame with the author’s screw-traction device attached. 

SO as to allow some motion at the joint; the olecranon wire was untouched. 
Roentgenograms taken at two-week intervals showed a rather slow 
formation of callus, but maintenance of the good position of the fragments. 
At the end of ten weeks the wdres, screws, and cast were removed without 
any anaesthetic. A light anterior splint wms Avorn for a few weeks more, 
just as a protection, and the patient was instructed to begin active motion 
of the involved parts. Four and one-half months after reduction he had 
normal use of all the joints of the left upper extremity. No deformity 
could be seen or felt. (See Figure 4.) The only signs of treatment were 
the small scars left by the -wires and screw^s. 

Figure 5 shows the additions to the fracture frame which the writer 
has made for handling such a case in the future. The adjustable screw- 
holding arms can be put into any position and they absolutely immobilize 
the fragments for the taking of roentgenograms and the application of the 
plaster cast. One of the, troublesome features in the case described was 
the manual holding apart of the upper fragments. 

The author feels that this method should be tried in all such cases 
which usually are subjected to operative means of reduction and retention. 


THE JOURNAE OF ROXE AND JOINT .SURGEIfi 




OSTEOMYELITIS OF THE PATELLA 

Report op Two Cases 

BY E. J. DITTRICH, M.D., FORT SCOTT, KANSAS 
From the Orthopaedic Service of Mercy Hospital 

Primary hematogenous osteomyelitis of the patella is such an un- 
common affection that our knowledge of it is gained almost entirely from 
the study of single cases. In many instances the diagnosis of this con- 
dition is not clear until a septic arthritis of the knee joint has occurred by 
extension of the destructive process. In the majority of cases the course 
of the infection is acute, and the involvement is so extensive that all or 
most of the patella is extruded in the form of sequestra. 

Case 1. L. D., white male, aged twelve years, was seen on January IS, 1935. 
In December 1933 he had injured the left knee when he stepped into a hole in a porch. 
There was no abrasion of the skin, but considerable pain and mild swelling were noted 
in the anterior portion of the knee. A splint was applied by the family physician. 
After several weeks this was removed, and the knee was swollen, painful, and tender. 
The condition improved gradually but always remained somewhat painful, especially 
on walking. A few weeks before examination the pain became more severe and a 
decided limp developed. 

Examination of the knee showed a moderate swelling over and around the patella 
with a mild degree of tenderness, most marked over the patella but involving also the 
joint line anteromedially and anterolaterally. There was a mild effusion into the joint. 
Motion was practically complete and produced very little pain. 

The patient was admitted to the hospital two weeks later. At this time there was 
an increase in the swelling and heat over the patellar region. Motion was free but pain- 
ful on extreme flexion. No abnormal mobility was noted. There was definite tender- 
ness over the patella, mostly in the lateral and superior portions. The patella was 
freely movable. Mild tenderness was present along the upper margin of the tibia antero- 
medially. The effusion in the joint had increased somewhat since the the first e.xamina- 
tion, but was entirely painless. Except for hypertrophied and chronically infected 
tonsils, the patient had no other abnormalities. 

Urine examination showed nothing abnormal. The leukocjde count was 12,000. 

Roentgenographic examination (Fig. 1) showed an irregularitj' of the contour of the 
lateral and superior borders of the patella, atrophy and cavitation of the anterior two- 
thirds, and a proliferative periostitis of the anterior surface. 

A diagnosis of osteomyelitis was made, and an operation was performed on Februarj’ 
9, 1935. A median longitudinal incision was made; the periosteum was reflected; and, 
with mallet and osteotome, the anterior portion of the patella was removed down to the 
cavities, one in tlie medial and one in tlic lateral portions of the bone. TIic cavities were 
from five to seven millimeters in diameter and contained soft, grayisli degenerated tissue, 
mucopurulent in character. This material was removed witli a curette. Due to tlie 
low virulence of the infection, it was decided to do a primary closure of the wound. 

Bacteriological examination showed a profuse growth of staphylococcus aureus. 

Tlic report of tlie pathological findings by Dr. C. A. Hellwig follows: “Grossly the 
bone appears partly necrotic and hemorrhagic. Micropscopically, the cartilage show.s 
deep fissures at the surface and the matrix shows degeneration. Most of the bone trabec- 
ulae have well-stained bone cells. There are a few spicules without definite nuclear 


von. XX. XO. I. JAXUAUY I03S 


209 



210 


R. J. DITTRICH 



Case 1. Roentgenogram of patella Case 1. Roentgenogram taken two 

before operation, show'ing cavities in 3 'earsafter operation, showing regeneia- 

both the medial and the lateral portions. tion of bone. 


stain. There are also small areas where new bone trabeculae are found. The bone tissue 
is replaced in manj^ areas by fibrous tissue which is cellular and infiltrated ivith p asma 
cells and a few leukocjdes. No definite abscesses are found. Pathological diagnosis. 

Subacute osteomyelitis.” . 

Following operation the patient’s temperature continued a septic course lo 
102.6). Considerable swelling appeared along the incision, and small amounts o pus 
were discharged, necessitating removal of the sutures. In addition, the knee join was 
distended gradually by effusion which w'as painless and evidently aseptic. . . nf 

On February 27, 1935, the joint was aspirated and seventy cubic centimeteis 
clear greenish fluid were withdrawn. Roentgenographic study on the same day ^ lowe 
that a portion of the patella involved in the destructive process was stiff presen , 
this, together with the other findings of a progressive condition, indicated that u 


operative measures w'ere necessary. . 

The next day the ’ivound w'as opened down to the bone. The anterior sui 
bone consisted of soft friable bone and granulation tissue. In removing , , ij 

portions of bone along the lateral border of the patella, an opening was den^ 

made into the joint, allowing about twenty cubic centimeteis o gieenis i ui 
into the wound. The wound w\as packed lightly w'ith vasehn gauze. nnd 

Followdng this procedure, the temperature rose to 100.2 degrees on 

third days, and then returned to normal. The amount of ^'^XSaytte «n- 
to day. On March 16, 1935, the vaselin gauze was removed. Aftei ten d y t 
age ceased, there w^as no tenderness or effusion of the joint, and “O ^ ‘ 

90 to 180 degrees. The patient had a complete return of fun ^ satisfactory 

respects normal. A roentgenogram (Fig. 2), taken m April , 

regeneration of the patella. . 

Case 2. R. C., white male, aged fifteen years was seen on May ^^9^37. 
the previous six months he had had occasional mi pain in ^ p ^.he knee was 

never severe enough to incapacitate him for ordinary activi ^ i gym- 

quite painful whenever it was injured. Disability was 

Lstic exercises at school. He could recall a number of mjunes to hj^knee, 
there had never been any abrasion of the skin or any sw effing J 

THE JOURNAL OF BONE AND JOINT SURGERY 




OSTEOMYELITIS OF THE PATELLA 


211 



Fig. 3-A 


Fig. 3-B 


Case 2. Eoentgenograms showing small area of destruction on posterior surface 
of patella. 

The patient had complete range of mo- 
tion in flexion and extension. There was no 
disturbance of gait, no swelling, and no 
effusion. Mild tenderness over a small area 
medial to the patella constituted the only 
positive finding. 

Roentgenographic study (Figs. 3-A and 
3-B) showed a small cavity on the posterior 
aspect of the patella. This was oval in shape 
and surrounded by a layer of condensed bone. 

A diagnosis of osteomyelitis was made. 

From the clinical course it appeared that 
this was at the time a benign process, al- 
though potentiallj' dangerous. For that rea- 
son it was considered advisable to remove 
the focus. 

Operation was undertaken on May 14, 

1937. After the anterior surface of tlie pa- 
tella had been exposed, a drill hole was made 
anteriorly. This was enlarged with a burr. 

•Mter the desired depth had been reached, the 
cavity was located with a small drill. The contents of the cavity consisted of dense 
fibrous tissue and soft granulation tissue. No pus was found. The margins of the cavity 
wore removed with a curette. The wound was packed lightly with vasclin gauze. 

Bacteriological c.xamination showed no culture. 

The report of the pathological findings by Dr. C. A. Hellwig read as follow.s: “There 
arc fragments of bone with hemorrhagic and inflammatory change.^. In one area there i.-^ 
noticed a necrosis of bone spicules surrounded by leukocytic infiltration of the bone 
marrow. Diagnosis: Osteomyelitis.” 

Following operation there was a moderate amount of ilminage, which decreased 
from day to day. .\ftcr two weeks the dniin was removed. Three weeks later the wound 
was healed. .\t the time when this report was written, the patient had been ambulant 



Fig. 4 


Case 2. Roentgenogram taken ten 
weeks after oper.ation, showing healing 
of bone. 


voi.. XX. N'o. 1 . j.\xr.\nY loss 






FRICTION VERSUS TRACTION 


A Simple Appliance foe Use in Making Traction to the Head 

BY ALBERT H. FREIBERG, M.D., CINCINNATI, OHIO 
From the Department of Orthopaedic Surgery, University of Cincinnati Medical School 

Maximum efficiency in applying traction to the head or to the extrem- 
ities is to be attained only by eliminating as far as possible the element of 
friction. By this is meant not simply friction in the mechanism itself, 
but, what is much more important, friction between the head or extremity 
and the surface of the bed upon which it rests. Failure to recognize this 
fact and to make provision for it has resulted only too often in dissatisfac- 
tion with the method or in the unnecessary and undesirable elaboration 
of apparatus and even of the plan of treatment. 

The author has long held the opinion, as the result of experience, 
that the sole virtue of the Russell (so-called “Australian”) method of 
traction to the lower extremity lies in holding the extremity suspended, 
so that friction is thereby rendered inoperative. This can be demon- 
strated by suspending the extremity in a sling from an overhead frame 
and by making traction at any desirable angle in the ordinary manner. 
The limb swings comfortably like a pendulum, and friction against the 
bed surface is completely eliminated. The weight of a leg in a number of 
adult males has been ascertained by means of an accurate spring balance, 
and it has been found to vary between fifteen and eighteen pounds. It 
follows that in practice this much weight must be used merely to over- 
come the friction factor before the tractive effect becomes evident at the 
desired point on the limb. This amount of weight is not only superfluous, 
but, when adhesive plaster is used, it causes the plaster to slip and to 
irritate the skin unnecessarily. While this method cannot compete in 
mechanical efficiency with traction upon bone by the insertion of metal 
pins, skeletal traction constitutes a complication which is frequentlj’’ both 
undesirable and unnecessary, especially when hospital care is not feasible. 
However, even when skeletal traction is employed, that amount of force 
which must be used merel}'" to overcome friction is wasted and undesirable 
if it can be shunted out altogether. 

The heads of fifteen recumbent male patients and of an equal number 
of recumbent female patients were weighed with the spring balance by 
Dr. William A. Bishop, Jr., the Ortliopaedic Resident at the Cincinnati 
General Hospital. Vfiiile there was some variation in weight according 
to size, the average weight was eight and one-half pounds. The heads 
of a number of children below the age of twelve were weighed in the same 
manner. The average weight of the head in jiafienfs between the ages of 
five and twelve was six and one-half pounds, although the variation was 


VOI,. XX. XO. 1. J.\XeAUY l!iss 


213 



212 


R. J. DITTRICH 


for five weeks, without any return of symptoms. Tliere was no swelling, tenderness, 
or restriction of motion. 

Roentgenographic examination (Fig. 4), on July 26, 1937, showed practically a 
complete regeneration of the bone with no evidence of destructive process. 

DISCUSSION 

In both of the cases reported the symptoms had been of long duration. 
They were mild in character; in fact, they were so inconspicuous that one 
would hardly suspect the true nature of the disease. From the roent- 
genographic appearance, it is also evident tliat the destructive process 
had been of long duration. It is possible that in some of the cases with 
an acute course a chronic infection has been present for some time previ- 
ous to the acute onset. This is especially to be suspected in those cases 
in which complete sequestration of the bone occurs early in the course 
of the disease. 

It is to be expected that a chronic focus of destruction, which is well 
defined in the roentgenogram, even though it is mild symptomatically, 
wull not indefinitely continue a benign course but will eventually become 
active. With this in mind, it is considered advisable, when the diagnosis 
is clear, to eliminate the destructive process while it is still in the chronic 
stage. 


THE JOURNAL OF BOXE AND JOINT SVRGVR'i 



FRICTION VERSUS TRACTION 


215 


the rollers will tend 
to move toward the 
lower or foot end by 
gravity. The head 
should rest upon a 
thin pillow of about 
the same size as the 
top board. (See Fig- 
ure 2.) Like eveiy 
other similar appli- 
ance, it requires occa- 
sional inspection dur- 
ing use in order that 
it may be kept con- 
tinuously effective. 

The rollers must be 
prevented from im- 
pinging upon then' up- 
per barriers and this will be apparent even to an untrained person. 

Experience with this appliance has shown two factors of no little im- 
portance. Since it is not necessary to emploj’’ about eight pounds of 
force to the heads of adults and correspondingly less in children, merely 
to overcome friction, the problem of a comfortable halter has become 
greatly simplified, even to the point of being non-existent. As a matter 
of fact, this involves the second factor, — we have found it unnecessaiy to 
use as much weight for effective traction as we were compelled to employ, 
by the old method, to overcome friction alone. Under continuouslj'- 
effective traction, not nearly as much weight is required as we had before 
thought necessaiy. The weight which we have emploj’^ed with this ap- 
paratus has varied between three and six pounds. This much weight is 
easil}’’ tolerated even with a halter improvised out of muslin bandage. It 
has also been found practical to make the head halter out of washable 
material. 

The appliance described has been used both for children and for adults, 
and for traumatic conditions as well as for disease of the eervical spine. 
It has given satisfaction in the hands of others, as well as in those of the 
author. It is applicable not onlj’’ in hospital practice, but also under 
quite adverse circumstances. 

The iiuthor is indebted to Mr. .Toseph Homan of the Department of Medical Art 
for his kindness in furnishing the illustrations. 



Vertical section of the apparatus in use: 1 , the tray; 2 , 
the top resting upon the rollers and covered with layer of 
sponge rubber; S, small pillow of the same size as the top; 
4 , the halter, which should impinge upon the chin and not 
upon the neck. 


von. XX. xo. 1 . jAXOAnv iP3s 



214 


A. H, FKEIBERG 



greater than in adults. If the weight of the head rests upon bed and 
pillow, as has been the usual practice in the past, a corresponding amount 
of force must be applied to the head merely to overcome friction and be- 
fore the cervical spine is subjected to the tractive effect in any adequate 
degree. This is true even with the insertion of pins into the skull for 
skeletal traction, and the use of this much force merely to suspend the 
head fulfills no other useful purpose. In the case of traction to the head 
for lesions of the cervical segment of the s])inc, howevei-, it has been found 
that great force is seldom, if evei’, necessaiy provided always that the force 

is efficiently applied. 

The simple ap- 
})liance which is shovm 
in Figures 1 and 2 is 
offered as a means of 
reducing friction to a 
minimum. It can be 
easily and rapidly im- 
provised in any ordi- 
narj'' shop, since it 
j-equires onlj'' such ma- 
terials as are every- 
where obtamable. The 
author has used it 
with great satisfac- 
tion for se^''eral years. 

The appliance 

(Fig. 1) consists of four separate pieces made of wood: 

1. A tray, eight by ten inches, made of thin wood; so-called "ply- 
wood ” is preferable, but not indispensable. To the four sides of its upper 
surface is fastened a rim of wooden strips, one-half an inch in height and 
in width, and the tray is divided into two equal compartments by another 
strip, of the same dimensions, placed transversely. 

2. Two dowel pins (wooden cjdinders) cut to such a length that they 
will roll easily in each compartment. Each pin should be five-eighths of 
an inch in diameter, so that it projects slightly above the height of the 
rim of the tray. 

3. A top of plywood or other thin wood, ten by ten inches, on which 
the head is to rest. To the upper surface of this there may be glued a 
pad of sponge rubber, a so-called kneeling pad such as may usually be 
found in the " five-and-ten-cent ” store. This pad is not indispensable, 
but it adds much to the patient’s comfort as well as to the efficiency of the 
apparatus. 

When the top is placed upon the rollers, it will move to and fro with 
friction reduced to a minimum, because the rollers are somewhat higher 
than the rim of the tray. In use, the appliance is placed under the 
patient’s head with its upper end slightly higher than the lower, so that 

THE JOURNAL OF BONE AND JOINT SUROEE' 


Fig. 1 

The tray, containing the two dowel cylinders, as seen 
from above. 


PRIMAKY BACILLUS-PYOCYANEUS ARTHRITIS 


217 


admission as having satisfactorily recovered. The use of autogenous vac- 
cine in the treatment of systemic diseases of bacillus-pyocyaneus etiology 
was reported by Wassermann as early as 1896 and is still accepted as the 
most advantageous attack on the inroads of pyocyaneus infection in in- 
ternal organs and in concealed tissue spaces. 

CASE REPORT 

R. B., a weU-developed and weU-nourished white male, aged three and one-half 
years, was admitted to the Orthopaedic Service of the Cincinnati General Hospital on 
February 2, 1937, with a swollen and painful right ankle. 

Fifteen months previously, on November 11, 1935, he had been admitted to the 
Dermatological Service with first and second degree burns involving about one-fourth of 
the body surface, including the right leg and foot. By the fourth hospital day, there had 
developed a rather severe pyodermia of the involved area with evidence of bacillus- 
pyocyaneous infection. Three weeks after entry, multiple subcutaneous abscesses had 
appeared, including one over the insertion of the Achilles tendon on the right. Roent- 
genograms of the right ankle were negative. A culture of the pus obtained at the time of 
incision and drainage showed, among other organisms, bacillus pyocyaneus. The 
temperature curve rose again ten days later, at which time repeated roentgenograms 
showed beginning destruction of the lower tibial epiphysis on the right. An incision and 
drainage of the ankle was done at that time, but, unfortunately, the pus was not cul- 
tured. The patient was discharged from the hospital on the 114th day after entry, 
March 3, 1936, as having recovered sufficiently to walk unassisted. He was to be fol- 
lowed in the Out-Patient Department, but he did not return. 

On readmission, his mother gave a history of his having had pain in the right ankle 
and a limp of about one week’s duration. Three days before admission, redness and 
swelling of the joint had developed; this was associated with an elevation of temperature 
and night sweats. The mother stated that for several weeks after leaving the hospital 
fifteen months previously, the patient had walked with a limp, but that this had com- 
pletely disappeared and for the past year he had had no complaints. 

Examination at the time of his second admission revealed a well-developed and 
well-nourished white male infant who was obviously acutely ill, but onlj' moderately 
toxic. There was swelling of the right ankle with redness of the overlying skin and in- 
creased local heat. Fluctuation was present below and anterior to both malleoli. 
Saphenous and femoral Ij'mphadenopathj’^ was quite obvious on the right side. 

Incision and drainage of the right ankle joint was done under strict aseptic tech- 
nique, and yielded a small amount of thick bluish-green pus. On smear and culture, 
only S-shaped rods of bacillus p 3 'ocyaneus were found. An autogenous vaccine was 
made, small doses of which were given intradcrmallj' on alternate daj’s. 

The cast was changed on the thirtieth day after admission, at which time the wound 
was well healed, and there was but little tenderness. The patient was discharged to the 
Out-Patient Department where vaccine therapy was continued for one month. 

SUMMARY 

In this case, the bacillus-pyocyaneus infection developed in an area 
of first and second degree burn of the leg. Subsequently, the infection 
involved the soft tissues about the ankle joint, followed b 3 ' roentgeno- 
graphic evidence of destruction of the distal tibial epiphj'.=is on the right. 
Fifteen months after rccoveiy, a pj'arthro.sis of the same ankle developed, 
from which a pure culture of bacillus pj’ocj'aneus was obtained. Recov- 
erj' ensued after incision and drainage of the ankle and autogenous- 
vaccine therapj'. 


VOI.. XX. NO. I. JANUAnV I03S 



A CASE OF PRIMARY BACILLUS-PYOCYANEUS ARTHRITIS 

IN AN INFANT 

BY W. A. BISHOP, JR., M.D., CINCINNATI, OHIO 
From the Department of Orthopaedic Surgery, University of Cincinnati Medical School 

Primary systemic infection by the bacillus pyocyaneus is sufficiently 
infrequent to merit discussion. This organism is usually considered as 
having a low pathogenicity, manifesting its presence occasionally as a sec- 
ondary invader in localized pyogenic processes. It is found as a second- 
ary invader in such conditions as furuncles, infected wounds, etc., most 
frequently being considered a nonpathogenic parasite. 

The bacillus pyocyaneus was first obtained by Gessard, in 1882, in 
pure culture from two cases of skin wounds showing bluish-green dis- 
coloration. Not long thereafter, the organism was found by numerous 
investigators in colored suppurations in various portions of the body. 
By 1897, the organism had been repeatedly found not only in open 
wounds, but also in generalized infections with severe constitutional 
symptoms, as reported by Baker. 

In a review of the literature in 1906, Roily collected a series of cases 
of infections of internal organs in which the bacillus pyocyaneus was 
either the sole or an associated invader. In this list were such diseases as 
perityphlitis, pyelonephritis, mastitis, and panophthalmitis; a case of 
prepatellar bursitis; and cases in wdiich fistulae were present. 

In a study of 12,000 autopsies, Fraenkel concluded that the bacillus 
pyocyaneus was the principal invader in only thirteen cases. In 1917, 
he presented a study of twenty-six cases of primary pyocyaneus invasion 
in which there were twenty-one children under two years of age and five 
adults. He observed cases of otitis, enteritis, ecthyma gangraenosum, 
endocarditis, meningitis, sepsis, and others, due directly to infection with 
this organism. He concluded that it may act not only locally with the 
production of toxin, but also through the actual invasion of internal or- 
gans; and he expressed the belief that, although this organism was rarely 
the primary cause of disease, nevertheless, the majority of such pyocy- 
aneus infections were acute and fatal almost without exception. The 
later articles concerning bacillus-pyocyaneus infection in man add noth- 
ing to this classical description. 

Although many instances of infection have been reported in which 
the bacillus pyocyaneus was the principal invading organism, a search of 
the literature revealed but one reference to primary joint involvement. 
This case wms reported by.Pinelli and was that of an eight-month-old in- 
fant with arthritis of the left shoulder from which was isolated a pure cul- 
ture of the bacillus pyocyaneus. The patient was treated with auto- 
genous vaccine, and "was discharged from the hospital two weeks after 

21G the journal of bone and joint SUKOEnl 



A SPECIAL BONE RETRACTOR FOR SUBTALAR ARTHRODESIS 

BY -WILLIAM H. VON LACKUM, M.D., F.A.C.S., NEW YORK, N. Y. 

From the New York Orthopaedic Dispensary and Hospital 


The technical difficulties frequently encountered in obtaining satisfac- 
torj'- exposure and visualization of the talocalcaneal joint in doing a sub- 
talar arthrodesis have led to an effort to simplify this step in the procedure. 



Fig. I 

Bone retractor, improvised from a Hamilton-Cook uterine dilator, for use in 
subtalar arthrodesis ; 

A; Adjustable lock screw. 

B: Steel pegs. 

C: Handles rotated 180 de- 
grees. 

For this purpose, 
a Hamilton-Cook 
uterine dilator has 
been converted into a 
partially self-retaining 
retractor, as seen in 
Figure 1, by rotating 
the handles 180 de- 
grees, and by applying 
an adjustable retain- 
ing screw and bolt to 
the handle, and sharp 
steel pegs to the tips of 
the blades. When in 
position, as shown in 
Figure 2, the instrument opens widely this hitherto relatively inaceessible 
talocalcaneal joint, so that the joint surfaces may be well visualized, thus 
greatlj’- facilitating the clean excision and reshaping of tlie joint surfaces. 

This instrument is particularly helpful in performing arthrodo.ses on 
immobile, arthritic, or post-traumatic feet, in which the talocalcaneal 
joint is involved. It has also been used to advantage in exiiosing the 
articular surfaces in fusion of tbe ankle joint. 



VOL. XX. XO. I. J.VN'UAHV 193S 


219 





218 


W. A. BISHOP, JK. 


REFERENCES 

Baker, L. F. : The Clinical Symptoms, Bacteriologic Findings and Postmortem Appear- 
ances in Cases of Infection of Human Beings with the Bacillus Pyocyaneus. J. 
Am. Med. Assn., XXIX, 213, 1897. 

Fraenkel, E. : Ueber Allgemeinlnfektionen durch den Bacillus p 3 mcyaneus. Virchows 
Arch f. path. Anat., CLXXXIII, 405, 1906. 

Weitere Untensuchungen iiber die Menschenpathogenitiit des Bacillus 
pjmcjmneus. Ztschr. f. Hj'g. u. Infectionskrankh., LXXXIV, 369, 1917. 

Gessard, Carle: De la pjmcj'anine et de son microbe, colorations qui en dependent dans 
les liquides organiques (pus et sdrosites, sueur, liquides de culture), applications 
cliniques. These de Paris, No. 248, p. 68, 1882. 

PiNELLi, A.: Artrite monoarticolare primitiva da piocianeo in una lattante di 8 mesi. 
Pediatria, XXXV, 147, 1927. 

Rolly, E. : Pyoz 3 mneussepsis, bei Erwachsenen. Miinchener med. Wchnschr., LIII, 
1399, 1906. 

Wassermann, a. : Experimentelle Untersuchungen iiber einige theoretische Punkte der 
Iminunitiitslehre. Ztschr. f. H 3 'g. u. Infectionskrankh., XXII, 263, 1896. 


the journal of bone 


AND JOINT SOROERY 



SCOLIOSIS TIIKATKD BV TIIK WKDGIXG JACKET 




A NEW KNIFE FOR USE IN REMOVING 
SEMILUNAR CARTILAGES 

BY PRANK A. LOWE, M.D., SAN FRANCISCO, CALIFORNIA, AND LOUIS W, 

BRECK, M.D., EL PASO, TEXAS 

In spite of the fact that the removal of a semilunar cartilage is a 
relatively common procedure for the orthopaedic surgeon, it is still a 
rather difficult one for many men, and occasionally even for the most 
dexterous. The hai'dest part of the procedure is the freeing of the car- 
tilage from its attachment. Due to the fact that the condyles of the 
femur are in close apposition to the upper end of the tibia, there is very 
little space in which to work, even if a large incision has been used. With 
a small incision, it is perhaps even more difficult. The most common 
method of freeing the cartilage is by means of a pair of scissors, and usually 
it is somewhat hard to insert them along the lateral and posterolateral 
attachments of the cartilage and to bring them into play. The surgeon is 
often forced to make numerous attempts, and, when he has finished, an 




irregular or serrated border of the cartilage is left and the removal is 
accompanied by more trauma than is desirable. 

We have designed a knife to be used in removing semilunar cartilages 
which we have called the Lowe-Breck cartilage knife, and we believe it to 
be quite an addition to the armamentarium used in this procedure. It is 
essentially an end-cutting knife with small guides on the sides of the blade, 
and the end of the knife is cuiwed to conform to the contour of the 
semilunar cartilage. Other end-cutting knives harm been devised for this 
piuqDOse, but we have been unable to find any knife similar to the one v e 
arc describing. 

220 the jouhxae of bone and joi.vt sonGEiri 



KNIFE FOR BEJIOVING SEMILUNAR CARTILAGES 


221 


Figure 1 shows the gen- 
eral construction of the knife 
which consists of a handle, a 
shaft, and a curved end, on 
the tip of which is a knife edge 
with a small guide on either 
side. The shaft and end to- 
gether measure six inches, so 
that the instrument is fairlj’- 
long. The curve involving 
the terminal one and one- 
fourth inches permits the 
blade to follow the border of 
the cartilage, for its contour 
corresponds to that of the 
meniscus. Inasmuch as the 
contours of the medial and 
lateral menisci are almost the 
same, and since the instru- 
ment is symmeti’ical, it can 
be used as well for one car- 
tilage as for the other. The 
end-cutting blade is effective 
and at the same time not 
dangerous, for the guides on 
each side prevent it from 
invading the tissues. The 
guides themselves are blunt 
and are not dangerous if 
handled with ordinary care. 

If this knife is used, the operator may choose the incision which he 
has found most successful. The semilunar cartilage which is to be re- 
moved is identified, and its front end is grasped with a strong clamp and 
freed with scissors for a distance of one-half to one inch. The cartilage 
knife is then placed along the attachment of the meniscus at the end of 
the scissors cut. The knife is adjusted so that its curve is accommo- 
dated to the contour of the cartilage. Pressure is then exerted on the 
knife and, as it cuts, the attachment is followed around until the cartilage 
is free. Once the knife is placed properly and the cutting has been begun, 
it is usually quite easy to follow the border of the meniscus, for the 
cartilage cuts fairly easily and the guides on the knife hold it in place and 
prevent it from slipping. Figure 2 illustrates the manner in which the 
instrument is used and shows how the curve on the end of the knife fits 
the contour of the cartilage. 

We have found the instrument very useful in a iiroeedure which is 
not always easy, and we hope that others may find it equally valuable, 

VOI., XX. XO. 1. I9.1< 



Fig. 2 

Diagrammatic drawing showing the top of the 
tibia with the cartilage knife in place and the 
meniscus half removed. 




PERONEAL-NERVE PALSY DUE TO COMPRESSION BY 

ADHESIVE PLASTER 

BY SETH SELIG, M.D., NEW YORK, N. Y. 

Adhesive traction as described by Russell ^ has become increasingly 
popular as a method of treating fractures of the shaft of the femur. 
While the physics of this method has been thoroughly described, little 
attention has been given to the technique of applying the adhesive to 
the leg. In any method in which traction is used, constant vigilance 
and frequent adjustments are necessary to maintain the efficiency of 

the method and to avoid complications. 

Recently five cases of pressure neuritis 
of the common peroneal nerve, caused by 
improperly applied adhesive plaster, have 
come to the writer’s attention. 

In two of the cases the adhesive had been 
applied for the purpose of making traction 
according to the method of Russell. One 
patient was a Avoman, seventy-nine years old. 
with an intracapsular fracture of the neck of 
the femur fixed by a metal screw, and Russell 
traction had been applied as an added safe- 
guard. At the time of her death from an 
infected decubitus ulcer, six Aveeks after the 
peroneal palsy had been noticed, there Avas 
methods of appijdng adhesive no improA'-ement in the neurological condition. 

elSreiSty^'^AnchoiingstiTpT second case of peroneal palsy occurred 

whether transverse or obliquel in a nine-year-old boy suffering from a hemo- 

are not shown in this illustra^ lytic-streptococcus infection of one hi]) Avhich 
tion and may be dispensed ^ . n-.! 

with. Avas treated in Russell traction, ihe nerve 

symptoms disappeared in six months. Both 
patients had complained of pain in the foot and along the anterior aspect 
of the leg for from one to seven days before paralysis appeared, and the 
pain Avas erroneously ascribed to the hip. The neuritis Avas due to direct 
pressure by a transverse strip of adhesWe used as an anchor for the longi- 
tudinal strips, crossing the upper end of the fibula and compressing the 
common peroneal nerve against the bone. 

In two cases the peroneal-nerve palsy folloAved continuous intra- 
Amnous injection into one of the leg veins as a postoperatiAm therapeutic 
measure. The neuritis in these cases Avas also caused by pressure of one 
of the transAmrse adhesive strips AAuth AA'hich the extremity had been 
strapped to an immobilizing board. 

A fifth case of common peroneal-nerve palsj'^ occurred after arthrot- 

222 tiik joiirn-al of bon'f an'u joint .'mROEin 



Fig. 1 

The two most common 



PEHONBAL-NERVE PALSY 


223 


omy of the knee joint for removal of a torn internal semilunar cartilage. 
The dressing was held in place by two strips of half-inch adhesive that 
encircled the extremity; the lower strip crossed the upper end of the fibula 
and compressed the common peroneal nerve. 

While there are many methods of applying adhesive traction, the 
two most common ones are illustrated in Figure 1. In both methods it is 
customary to apply oblique or transverse adhesive strips to anchor the 
longitudinal ones. Over all of these strips a bandage, preferably of the 
elastic type, should be applied. Care must be taken to avoid placing 



Improperly applied traction. The 
oblique anchoring strips cross the fibula 
near its upper end where there is danger 
of injuring the common peroneal nerve. 



Properly applied adhesive in which 
no transverse strips cross the upper 
three inches of the fibula. The trans- 
verse strips may be dispensed with. 


either the transverse or the oblique strips across the upper three inches 
of the fibula, because it is at this point that the peroneal nerve is superficial 
and readily compressed against the underl 3 dng bone. (See Figures 2-A 
and 2-B.) 

Care must also be used in applying the distal, transverse, or oblique 
turns of adhesive which pass over the anterior aspect of the ankle joint. 
If these have been applied too tightly or too near the dorsum of the foot, 
the inevitable slipping of the side strips causes them to cut into the soft 
parts. 

Any complaint of pain in the leg or foot in a patient with adhesive 
traction or dressings about the knee joint should be carefullj’- investigated. 
This also applies to cases in which the limb has been immobilized in a 
plaster bandage, as we are all familiar with common peroneal-nerve pals}' 
due to pressure of a plaster bandage over the upper end of the fibula. 

1. Russell, R. H.: Fracture of the Femur; A Clinical Study. British .1. Surg., 
XI, 491, 1924. 


VOL. XX. XO. 1. JANUARY I93S 


AN ADAPTATION OF THE BALKAN FRAME FOR DEVELOPING 
MOTION AND ABDUCTION OF THE HIP 

BY PAUL L. NORTON, M.D., AND FRED ILFELD, M.D., BOSTON, MASSACHUSETTS 

From the Orthopaedic Service of (he Massachiisells General Hospital, Boston 

The traction-suspension apparatus described here was evolved pri- 
marily to meet the need of early mobilization of the hip joint following 
surgery, particularly acetabuloplasties and arthroplasties.^ 

In these particular operations, early motion in flexion and abduction 
is essential to a successful result. The ordinary traction-suspension de- 



Fig. 1 


vice allows adequate flexion of the hip, but does not permit enough a 
duction. With a Balkan frame as the foundation, the ordinary type o 
traction-suspension has been modified to allo'W wide abduction. T le 
apparatus has been used in over forty-five cases of hip-joint surgeiy, u 
its use need not be restricted to that particular joint. 

Passive hip motion in flexion and abduction is started in traction 
suspension on the third or fourth day postoperatively, and usua y 
the end of the first week the patient is encouraged to try active mo\e 

094 THE JOURNAL OF BONE AND JOINT SURGERl 




ADAPTATION OF THE BALKAN FRAME 


225 



ments. The motions of abduction, flexion, and knee extension are 
stressed. At the end of two or three weeks the apparatus is removed 
and the patient is allowed up in a Avalker for one week and is discharged 
walking with crutches. 

Figures 1 and 2 illustrate two types of traction-suspension both hung 
from the standard Balkan frame. Any hospital treating fractures or 
special orthopaedic cases will have the necessaiy articles for setting up 
this device. 

After moleskin adhesive has been applied to the lower leg, a Hodgen 
splint with a Pierson attachment is fitted to the extremity. Traction is 
maintained by a piece of tourniquet rubber tubing tied to the end of the 
Pierson attachment and fixed to a footpiece (omitted in the drawing). 
A three-pound weight, hung over the end of the bed on a swivel pullc 3 ', 
maj’’ also be used. If heavier traction is indicated, a Thomas ring siilint 
should be used in place of the Hodgen splint. 

The ring end of the splint is held in place b\' a ten-iiound weight 
(A) and the distal ends of the Pierson attachment and the splint arc con- 
trolled bj' ropes leading to the handles (B and C). 


VOI., XX. XO. 1. JAXLWnY 193S 



226 


P. L. NORTON AND F, ILFELD 


A pulley (D) is placed on the rope fastened to the lower end of the 
Pierson attachment. This pulley allows greater lateral motion and keeps 
the splint from rotating. 

A Russell-traction cndpiccc is fastened onto a crossbar as shown in ’ 
the insert E. Ropes then run from each side of the Pierson attachment 
through the lateral pulleys {F and (?) to a crossbar at the head of the bed 
where they attach to three-pound weights (Jl) pulling through a second 
set of pulleys. 

Handles are placed on these lateral ropes so that by pulling on them 
the patient may abduct or adduct the leg. 

Traction on B flexes the hip with the knee extended. Traction on 
C flexes the hip and the knee. The hip may be flexed by pulling on C 
while the knee is passively flexed and extended by means of alternating 
traction on B. 

The tyiDe of apparatus in Figure 2 may be arranged more quickly 
and allows easier lateral motion. Tlie leg is placed in a Hodgen splint 
in traction and balanced with a five-pound weight. The assembly is sus- 
pended from a standard Balkan frame. The distal end of the splint is 
attached to a pulley which moves on a'steel bar * ; this allows wide abduc- 
tion. The lateral ropes are run through pulleys on a special crosspiece 
as shown in the drawing. Flexion and extension of the knee are illus- 
trated in the lower diagrams. Abduction of the hip is routinely per- 
formed in varying degrees of flexion. 

* The bar is made of one-half inch cold rolled steel and is bolted to a piece of joist 
four feet long and one inch by one and three-quarter inches in cross-section. The dis- 
tance between the joist and the rod is two and one-half inches. 

REFERENCES 

1. Russell, R. H.: Fracture of the Femur. British J. Surg., XI, 491, 1924. 

2. Smith-Petersen, M. N. : Treatment of Malum Coxae Senilis, Old Slipped Uppei 
Femoral Epiphysis, Intrapelvic Protrusion of the Acetabulum, and Coxa Plana by Means 
of Acetabuloplasty. J. Bone and Joint Surg., XVIII, 869, Oct. 1936. 


THE JOUnXAL OF BOXE AX'D 


JOIX'T SUnGEIl'i 



A TRACTION APPARATUS FOR FRACTURES OF BOTH BONES 

OF THE FOREARM 

BY EDWARD N. REED, M.D., SANTA MONICA, CALIFORNIA 

The apparatus shown in Figure 1 was developed to overcome the 
awkwardness of the Soutter reduction apparatus when applied to forearm 
fractures. 


CONSTRUCTION 

The bases which screw on the table are made of boiler plate, folded 
to form a channel; one side of each base is drilled and threaded for thumb 
screws. The uprights are made of flat crucible steel, 12 or 14 gage, bent 
to shape and riveted into the bases. The screws are threaded steel rods 
which run through a short piece of Shelby tubing that projects far enough 
to form a shoulder against which the winged nut bears. On one side, 
the screw of an ordinary C clamp, four or five inches in length, is used 
because the pitch of the thread is steep and the screw is, therefore, rapid 



in action. The end of the C clamp which carries the screw is sawed off 
with a hack saw, drilled, threaded, and mounted on the uiiright with 
machine screws. The swivel cap which is standard on the end of the 
C-clamp screw is drilled and threaded, and a cro.sspiece is fastened to it 
with machine screws to give attachment to the rings at the ends of the 
cuff straps. The wrist cuff is made of soft leather, it encircles the wrist 
twice, and it is fastened with a buckle. At the elbow, soft webbing is 
a]iplicd in the figure-of-eight manner. 

TECHNIQUE 

By means of this apiiaratus, graduated traction is apjilied for regular 
periods of time with a relaxation interval of two or throe minutes every 

2J7 


VOI., X.X. NO. I, JAKUARV I!>3S 



228 


E. N. UEKI) 


five minutes. Fifteen pounds of traction is used at first and this is in- 
creased by five pounds at each period, as recommended b}'- Dr. Soutter. 
After twenty to thirty minutes, muscle relaxation is usually complete, and 
there is an interval of six or eight minutes during which the fragments can 
be maniiDulatcd into jmsition. 

After the position of the fragments has been checked with the fluoro- 
scope or roentgenograms and found satisfactoiy, a circular cast is applied 
from the elbow cuff to the Avrist culT. This is carefully molded over the 
dorsal and ventral interosseous spaces in an attemjjt to maintain separa- 
tion of the radius and the ulna. When this ]7art of the cast has thor- 
oughly set, the traction is released, the cuffs arc removed, and the plaster 
is continued up over the elbow to the middle of the ujiijer arm, and down 
oAmr the wrist to the heads of the metacarpals. 

ADVANTAGES 

The apparatus can bo attached to any table in a few moments by 
four thumb screws. Since it is fixed to a table, it is steady. It holds the 
arm up from the table, permitting the taking of roentgenograms or the use 
of the fiuoroscope and the application of a plaster cast over the greater 
part of the forearm, while maintaining traction. Detached from the 
table, it weighs only a few pounds and can be packed in a small box. 


THE JOURN’AE OF BOXE AND 


JOINT SURGERV 



NEW TECHNIQUE IN THE TREATMENT OF FRACTURES 
OF THE FOREARM * 

BY LELIO ZENO, M.D., ROSARIO, ARGENTINE REPUBLIC 


Fractures of the forearm, Colies’ fracture, and fractures of the diaph- 
ysis of either radius or ulna, or of both bones, may be reduced by traction 
on the hand with flexion of the elbow to a right angle, allowing counter- 



traction of the arm. One or more assist- 


ants are needed, and the surgeon cannot 
always be sure that proper traction and 
countertraction are maintaining the frag- 
ments in a satisfactory position while the 



plaster-of-Paris bandage is 
being applied. Sokolowskj'- 
of Warsaw has devised an 
apparatus which simplifies 
this procedure. (See Fig- 
ures 1-A and 1-B.) Re- 
duction of the fracture 
fragments in the corrected 
position is maintained and. 



Fig. I -A Fig. 2-.A Fig. 2-B 

Sokolowsky’s appliance for Fixation In- skeletal pins in plaster, 

reduction of fractures of the 
forearm. 

at the .same time, the bandage can be aji- 
lilied with ease. The aiijiaratus may also be used for fractures of lioth 
hones when the direct ojien operative mctliod has been undertaken to 
obtain a more effective reduction. 

The difficulty of adequate stead\-ing of an oiilique fracture of the 
forearm, or of a comminuted intra-articular Colics’ fracture, is well known, 


* Read at the .\nnual Moctinp of the .-\mcrican Orthopawlic .Vssociation, Lincoln, 
Xebraska, .lunc 3, 1937. 


VOI.. XX. XO. I. JAXr.MIY 


220 


230 


LELIO ZENO 


even when plaster splints are employed without padding. For these cases 
Bolder suggests combined fixation by means of a plaster-of-Paris dressing 
and two non-rusting wires jjassed through the bones and pulled taut, their 
ends embedded in the jDlaster. This steadying combination, a decidedly 
efficient one, is made easily and neatly with the aid of Sokolowsky’s ap- 
paratus. (See Figures 2-A and 2-B.) 


Correction 

Dr. Leo Mayer of Ne^^■ York has icquested that \re publish a coi'rection m In^ 
article entitled “The Importance of Early Diagnosis in the Treatment of 
Femoral Epipltysis”, published in The Journal for October 1937. On page 10 , 
eleventh line in the third paragraph should read; “The leg is then immoin'Iixed in p as 
of-Paris in a position of abduction and internal i-otation.” 


THE JOURXAL OF BONE AN'O 


JOIN'T SUnOEB'' 



PERCY WILLARD ROBERTS 
1867-1937 

Perc3' Willard Roberts passed away on November 8, 1937, at the Hospital for the 
Ruptured and Crippled, after an illness of only two days. 

Dr. Roberts was born on January 10, 1867, in Janesville, Wisconsin, but he spent 
his earlj' j-ears in Milwaukee. At the age of eighteen, he went to San Francisco to be- 
come a reporter on the Chronicle and here earned his funds to study medicine. He 
graduated from Boston University School of Medicine in 1894. He then carried on a 
general practice in Bath, Maine, but, after ten j'ears, the ambition to become an ortho- 
paedic surgeon led him to New York in 1904, where he received an appointment at the 
Post-Graduate Hospital. The late Dr. Henrj' Ling Tajdor recognized his ability and 
gave him an appointment at the Hospital for the Ruptured and Crippled in 1907, where 
he also worked under the late Dr. Virgil P. Gibnej' and on up through the various grades 
to Chief of a Division. He retired from active hospital work in 1934, but retained his 
private practice and was a consultant at many hospitals in New York. 

Dr. Roberts contributed often to the literature and will be remembered for the opera- 
tions and apparatus which he devised, as well as for his interest in the subject of congeni- 
tal syphilis which made many realize that this disease was more often the cause of 
orthopaedic conditions than was formerlj' believed. 

Dr. Roberts was always a kind gentleman, with a genial smile and a sense of humor, 
and was greatty admired and respected bj"^ his patients. He was alwa3"S extremety 
mild-mannered, and even in the face of difficulties he appeared calm and unworried. 
Man3’ times he went through various crises which must have perturbed him, but he never 
showed it outwardty. He was always 103ml and cooperative and had a personality that 
would keep a group of men working together without friction. Those who worked 
with him and under him will feel a great loss in his passing. 


EDWARD SPARHAWK HATCH 
1875-1937 

Edward Sparhawk Hatch, one of the outstanding orthopaedic surgeons of the 
South, died suddenty on October 20, 1937. He was born in Boston on Februar3’- 2, 1875. 
He graduated from Harvard University in the Class of 1897 and from Harvard Medical 
School in the Class of 1899. He devoted a few years to general practice in Boston, 
but his interest soon turned to orthopaedic surger3^ He became affiliated with Carne3' 
Hospital in Boston, and from that time dates his active part in this specialty. 

In 1905 Dr. Hatch moved to New Orleans. He became a pioneer in orthopaedic 
surger3' in that part of the South where he pla3’ed an important role in the establish- 
ment of this specialty. In addition to an active private practice and to his work in re- 
search, he was Professor of Orthopaedic Surger3’ in the Post-Graduate Department of 
Tulane Medical School; chief of the Department of Orthopaedic Surger3’ in Tuoro 
Infirmar3’; and had also been chief of the departments of orthopaedic surgor3' in several 
of the medical institutions in New Orleans and vicinity. During the World War he 
served in the Medical Corps of the United States Arm3-. Fifteen 3’ears ago Dr. Hatch 
opened the first clinics for crippled children in Lake Charles and I>afa3’ette, I>ouisiana. 
He was still activety interested in the Clinic in Lafa3'ctte at the time of his death. 

Dr. Hatch alwa3’s took an interest and pla3'cd an active part in the medical societies. 
He had been Chairman of the Orthopaedic Section of the American Medical Association, 
as well as of the Southern Medical Association, President of the Clinical Orthopaedic 
Society, and he was a member of the .\merican Orthopaedic As.sociation, the .American 
Acadenw of Orthopaedic Surgeons, and a Fellow of the College of Surgeons. 

In Fcbruar3- 1937, Dr. Hatch .suffered a fracture of the spine, but ho did not allow this 
to interfere with his act ivit3- for after rocoverv- he rc.sumod and carried on his usual practice. 

Ho was always a good friend, and his genial personalit3- will be missed 1)3- his friends. 
He loaves a widow and two children, — a married daughter .and a son. 


VOI.. XX. XO. 1. JAXU.MIY ISSR 


2.31 



6 


F. L. BUTTE 


Case 1 {Figures 1, 2, 3, and 4) 

B. B., female, aged fourteen years, had an "idiopatliic” scoliosis, the 
primary right curve extending from the sixth thoracic to the second lum- 
bar vertebra, with the apex at the tenth thoracic vertebra. She had had 
jacket correction and spine fusion two years before coming to this Clinic, 
the fusion having been done from the fifth thoracic vertebra down to and 
including the eleventh thoracic, but omitting the lower three vertebrae of 
the primary curve. Figure 1 shows clearly that there had been an increase 
or recurrence of the deformity at these three joints — eleventh thoracic to 
second lumbar — and that as the result of this the trunk was shifted to the 
right side. Fusion appeared solid from the fifth to the eleventh thoracic 
vertebra. 

A pelvic-tilt examination was made, the patient sitting unassisted 
with the left side of the pelvis elevated. (See Figure 2.) This demon- 
strates the flexibility and muscle power at the lower lumbar joints and 
shows the extent to which the compensatory curve in this area might be 
expected to straighten under its own muscle power after correction and 
fusion of the primary curve above. In this instance only slight correction 
of the low lumbar compensatory curve is obtainable. 

After the desired correction of the primary curve (in this case the 
maximum obtainable) had been achieved in the wedging jacket, a roent- 
genogram was taken with a skin marker on the spine of the first lumbar 
vertebra (Fig. 3). This film was studied to determine the exact extent 
to which fusion should be done. The final total alignment of the trunk 
after extension of the fusion into the lumbar area depends upon the align- 
ment within the fusion area and the power of the unfused lower lumbar 
spine to bring this fusion area into the erect compensated alignment. The 
balance between these two areas may be visualized by superimposing the 
proposed fusion area, as shown in the immediately preoperative marker 
roentgenogram, upon the lower area, as shown in the pelvic-tilt roent- 
genogram. 

In the present instance, allowing for the usual slight loss of correction 
during the £rst year after fusion, it will be seen that the lower surface of 
the third lumbar vertebra (dotted line, Fig. 3) will be very nearly trans- 
verse to the axis of the corresponding segment of the trunk. It should sit 
squarely upon the upper surface of the fourth lumbar vertebra, which, in 
the pelvic-tilt examination, is seen to be nearly transverse to the body axis 
(dotted line. Fig. 2). The total alignment of such a combination is good 
(Fig. 4). Therefore, in April 1934, fusion was extended downward to 
include the third lumbar vertebra, one vertebra beyond the primary 
curve. 

Figure 4, taken three years after operation, shows the total align- 
ment to be good. All correction has been maintained at each joint except 
for slight loss between the eleventh and twelfth thoracic vertebrae, 
and the fusion is solid from the fifth thoracic to the third lumbar vertebra. 
The result is tliat which should be visualized on superimposing or setting 


THE JOURN'AL OF BON'E AND JOINT SURGERY 



NEWS NOTES 


233 


Cord Injury and Vertebral-Column Fracture. 

Dr. William A. Rogers, Boston, Massachusetts. 

Crush Fractures of the Spine. 

Dr. John Dunlop, Pasadena, California. 

Crush Fractures of the Spine. 

Mr. R. Watson Jones, Liverpool, England. 

The Treatment of Paralytic Bladder in Cases of Cord Injury. 

Dr. Frank Hinman, San Francisco, California. 

Rupture of the Intervertebral Disc as the Cause of Low-Back Pain with Unilat- 
eral Sciatic Radiation. 

Dr. J. M. Robinson, San Francisco, California. 

Tensile Strength of the Anterior Common Ligament. 

Dr. A. G. Davis, Erie, Pennsylvania. 

Afternoon Session 

The First Stages of Coxa Plana. 

Dr. Henning Waldenstrom, Stockholm, Sweden. 

Manipulative Surgery. 

Dr. Philip Lewin, Chicago, Illinois. 

Manipulative Method of Treatment of Backache. 

Dr. F. A. Jostes, St. Louis, Missouri. 

Some Problems of Bone Growth. 

Dr. J. B. deC. M. Saunders, San Francisco, California. (By invitation.) 

Dr. V. T. Inman, San Francisco, California. (By invitation.) 

Posterior Hernia of the Knee Joint (Baker’s Cyst), a Cause of Internal Derange- 
ment of the Joint. 

Dr. G. E. Haggart, Boston, Massachusetts. 


Thursday, January 20 

Morning Session 

Avulsion Fractures of the Greater Trochanter of the Femur. 

Dr. Henry Milch, New York, N. Y. 

Opposition of the Thumb. 

Dr. Sterling Bunnell, San Francisco, California. (By invitation.) 

The Healing of Joint Fractures: A Clinical and Experimental Study. 

Dr. K. O. Haldeman, San Francisco, California. 

Healing of Fractures of Atrophic Bones: A Clinical and Experimental Study. 

Dr. E. L. Compere, Chicago, Illinois. 

Bone Block for Painful Hips. 

Dr. J. B. L’Episcopo, Brookljm, New York. 

Executive Session — 12:00 Noon 
Afternoon Session 

Results of Treatment of Slipping of the Upper Femoral Epiphysis b 3 ’ Nailing. 

Dr. Philip D. Wilson, New York, N. Y. 

The Operative Lengthening of the Tibia and Fibula: A Further Development in 
Principles and Technique. 

Dr. L. C, Abbott, San Francisco, California. 

Dr. J. B. dcC. M. Saunders, San Francisco, California. (Bj- invitation.) 
Roentgen-Raj' Evidence of Metastatic Malignancj- in Bone. 

Dr. Henrj’ Snurc, Los Angeles, California. (Bj- invitation.) 

Experience with Bone Tumors at the Boston Citj- Hospital from 1932 to 193G. 

Dr. R. F. Sullivan, Boston, Massachusetts. 

Treatment of Fibrocj’stic Cavities in Bone bj- Curettage and Packing witli Bone 
Chips. 

Dr. W. E. Swift, New York, N. Y. 

Dr. Halford Hallock, New York, N. V. 


VOI. NX. NO. I. JAXUAllY IMS 



News Notes 


The Sixth Annual Convention of the American Academy of Orthopaedic__^Sur- 
geons will be held in Los Angeles, California, January 16 to 20, 1938, under the presi- 
dency of Dr. A. Bruce Gill. The headquarters will be at the Biltmore Hotel and the 
following program has been arranged: 

Tuesday, January IS 

M orning Sessiori 

Sacro-Iliac Fusion: A Modification of tlie Smitli-Pctersen Technique. 

Dr. A. F. O’Donoghue, Sioux City, Iowa. 

Two-Stage Extra- Ai'ticular Knee-Joint Fusion for Tuberculosis. 

Dr. Don King, San Francisco, California. 

Treatment of ExL-eme Flexion Contracture at the Knee Joint. 

Dr. S. L. Haas, San Francisco, California. 

A Procedu 2 'e for the Coia-ection of Internal-Rotation Contractui'es of the Thigh in 
Spastic Paralysis. 

Dr. H. A. Dui’ham, Shreveport, Louisiana. 

The Evaluation of Surgical Procedures on Bones, Muscles, and Peripheral Nerves 
in Spastic Paralj'sis. 

Dr. L. C. Wagner, New York, N. Y. 

Dr. Francis J. Carr, New York, N. Y. 

Dr. Arthur Thibodeau, New York, N. Y. 

Executive Session — 12:00 Noon 

Afternoon Session 

President's Address. 

Dr. A. Bruce Gill, Philadelphia, Pennsylvania. 

Non-Union and Bone-Graft Symposium — Dr. N. T. Kirk, San Francisco, Chairman. 
Massive Onlaj'' Graft in Ununited Fractures of the Long Bones, with Report of 
End Results. 

Dr. Willis C. Campbell, Memphis, Tennessee. 

Bone Grafts in Ununited Fractures. 

Dr, M. S. Henderson, Rochester, Minnesota. 

Inlay Grafts and Intramedullary Pegs in Ununited Fractures. 

Dr. Edwin B. Ryerson, Chicago, Illinois. 

Treatment of Non-Union of Fractures with Particular Reference to the Humeius. 

Dr. G. E. Bennett, Baltimore, Maiyland. ^ . 

Transplantation of the Fibula in the Leg: (a) For Large Defect in the libia, 
(b) Transfer of Upper End to Restore Ankle Mortise. 

Dr. W. B. Carrell, Dallas, Texas. 

Wednesday, January 19 

M orning Session 

Symposium on Fractures of the Spine — Dr. A. G. Davis, Erie, Chairman. 

First Aid and Transportation of Suspected Spine Injuries. 

Dr. J. E. M. Thomson, Lincoln, Nebraska. 

Indications for Operation in Cord and the Caudal Injuries. 

Dr. Howard C. Naffziger, San Francisco, California. 

Evaluation and Treatment of Acute Cervical-Spine Injuries. 

Dr. W. Ga 5 de Crutchfield, Richmond, Virginia. 


232 


THE JOURNAL OF BONE 


and joint SURGEIO 



NEWS NOTES 


235 


The Twelfth Congress of the Deutsche Gesellschaft fiir Unfallheilkunde, Ver- 
sicherungs- und Versorgungsmedizin was held in Wurzburg on September 24 and 
25, 1937, under the presidency of Prof. Dr. Reichardt, the distinguished alienist. 

The very full and interesting program, although devoted chiefly to psychological 
and neurological subjects, included the following communications of orthopaedic interest: 

Dr. Vogler, of Stettin, reported on lumbar puncture in head injuries, with especial 
reference to American practices. He demonstrated the good results of this method 
by a large amount of statistical material. 

Dr. Demme, of Hamburg, discussed nerve injuries caused by intramuscular injec- 
tion. His experiments on animals proved that India ink injected into the nerves of the 
leg penetrated the nerve roots. 

Dr. Wanke, of Kiel, described his investigations on the lumbago and scalenus- 
muscle syndrome. 

Of especial interest was the discussion by Dr. vom Stracke, of Erlangen, on the so- 
called traumatic neurosis. 

The next Congress will be held in Giessen in 1939 under the presidency of Prof. 
Dr. A. W. Fischer. 


The Nineteenth Congress of the Societe Franpaise d’Orthopedie et de Trau- 
matologie was held in Paris on October 7, 8, and 9, 1937, under the presidencj’^ of 
Prof. Etienne Sorrel. 

The “Orthopaedic Days”, October 7 and 8, were spent in visiting the Services of 
Prof. Ombredanne, Dr. Mathieu, Prof. Sorrel, Dr. Leveuf, and Dr. Boppe, where 
operations were demonstrated and patients were presented. 

Prof. Sorrel opened the Congress with a paper on the growth of orthopaedics in 
France and its present tendency to become more and more surgical. He expressed the 
hope that France would soon follow in the wake of other countries and establish services 
devoted exclusively to orthopaedic surgerj'. 

The two main subjects considered by the Congress were as follows: 

The Transplantation of Tendons in the Treatment of Club-Foot — Dr. Jacques Leveuf, of 

Paris, and Dr. A. D. Perrot, of Geneva. 

The first part of the discussion was confined to three topics: 

1. Tlie conditions necessarj' for a successful transplantation: 

a. Integrity of the muscle itself. 

b. Integrity of tlie structures used for the protection of the tendon. 

c. Fixation of the tendon. 

d. Tension on the transplanted muscle. 

e. Postoperative care. 

2. Functional adaptation of tlie transplanted muscles. 

3. Reestablishment of the muscular equilibrium. 

The second portion of the report dealt with the .special indications for transplanta- 
tion of tendons in the following conditions: (1) paralysis of the triceps surae; (2) paralysis 
of the tibialis anterior; (3) paralysis of the supinators; (4) paralysis of the pronators. 
The use of this procedure in pes equinus and pcs cavus was also discussed, although these 
affections are not the direct result of paral 3 'sis. 

liilatcral Coxalgia — Dr. Louis Allard, of Berck. 

-•Vftcr having given the clinical description of bilateral coxalgia and its progno.-^is. 
Dr. Allard confined himself to the treatment of this affection. He concluded that the 
treatment should first strive for anatomical cure of the focus in good position. After 
this has been obtained, one should use the utmost care to prevent .sequelae. Each case 
has its own indications, .\mong the procedures to be coii.sidcrcd are those .simple opera- 
tions without danger, — namel_v, osteotomy for correction and arthrodesis in certain 
cases. Operations for mobilization should be seriouslv debated and should not be ad- 
vi.sed without warning the patient of jiossible failure. Dr. .\llard favored the ida-tic 


VOI. .\x. NO. 1, JANl'AnV ISIS 



234 


NEWS NOTES 


Dr. Frank R. Ober, Assistant Dean of the Harvard Medical Scliool, has been made 
Professor of Orthopaedic Surgery at the University of Vermont. 


Prof. Etienne Sorrel, of Paris, announces the removal of liis office to 123, rue de Lille. 


Dr. William J. Stewart announces the opening of an office at 401 Guitar Building, 
Columbia, Missouri. 


The Seventh Walter M. Brickncr Lecture was given at the Hospital for Joint 
Diseases on Thursday evening, November IS, 1937, by Dr. Sterling Bunnell of San 
Francisco. The subject of the lecture was “Reconstructive Surgery of the Injured 
Hand”. 


A joint meeting of the Deutsche Gesellschaft fiir Chirurgie and the Deutsche 
orthopadische Gesellschaft will be held in Berlin on April 21, 1938, at the Langen- 
beck-Virchow-Haus. The special subject for discussion will be “Traffic Accidents”. 


The Third Annual Meeting of the Orthopaedic Guild was held on November 
26 and 27 in Richmond, Vii'ginia, with Dr. T. F. 'Wiieeldon as Chairman. The next 
Meeting will be held in Toi'onto on November 25 and 26, 1938, under the Chairmanship 
of Dr. A. W. Farmei'. 


The Polish Society of Bone and Joint Surgery and Traumatology will hold 
its ne.\t meeting in Poznan on April 2 and 3, 1938. The discussion at this meeting will 
be confined to two subjects; “Infantile Paralysis”, by Prof. Raszeja; and “Interarticular 
Fractures”, bj^ Prof. Gruca. 


The Sixty-Seventh Annual Meeting of the American Public Health Association 
will be held in Kansas Cit}'-, Missouri, on October 25 to 28, 1938. Dr. Edwin Henry 
Schorer, Director of the Kansas City Health Department, has been appointed Chair- 
man of the Local Committee. He will be assisted bj^ a large group of cit}’’ and state offi- 
cials and community leaders. 


The Clinical Orthopaedic Society met in Chicago on October 14, 15, and 16, 
to celebrate its Silver Anniversary and to honor Di'. John Lincoln Porter, its first 
President. 

Most interesting and instructive clinics were presented at Cook County Hospital, 
the Research and Educational Hospitals of the University of Illinois, St. Luke’s Hos- 
pital, Albert Merritt Billings Hospital, and Northw’estern University Medical School. 

The meeting was climaxed by the annual banquet held on Fridajq October 15, at the 
Palmer House. The banquet was under the direction of Dr. J. E. M. Thomson, Presi- 
dent of the Society, and Dr. Albert H. Freiberg, Toastmaster. A gold medal with the 
inscription “To Dr. John Lincoln Porter, The Founder of The Clinical Orthopac ic 
Society” was presented to the guest of honor bj'- Dr. A. Bruce Gill. A short acceptance 
address was made by Dr. Porter in his usual sincere and modest style. Bronze ^ ® 
of Dr. Porter, made from a wood carving bj' Dr. J. E. M. Thomson, were presente o 
the members. The John Lincoln Porter Lecture was given by^ Dr. Willis C. Campbe , 
who spoke on the subject of “Malunited Fractures”. Additional remarks were made 
by Dr. Samuel Kleinberg, Dr. E. W. Ryei-son, Dr. Melvin S. Henderson, Di . - rt lur 

Steindler, and Dr. Philip Lewin. t- u f 

The next meeting will be held in Nashville and Birmingham during the Fall o 

THE JOUnXAL OF BONE AND JOINT SUnonaX 



NEWS NOTES 


237 


siderable shortening (in this operation the anteversion is adjusted at the same time); 
( 3 ) detorsion operation bj* an oblique intertrochanteric osteotomj’^, used with the shelf 
operation in cases of subluxation combined with anteversion and valgositj* of the neck. 
He reported satisfactoiy results in adolescents and in adults, but emphasized the need 
of operation where possible in earlj' childhood — ^between the ages of three and six years — 
as the results are better than at a later age. 

Prof. Spisic showed a film demonstrating the non-operative treatment and em- 
phasized the need for instruction of the general public so that congenital dislocation 
could be treated at as early an age as possible. In his treatment he used also Putti’s 
and Hilgenreiner’s splints. 

Prof. Rocher discussed the end results obtained by the non-operative treatment. 
Examination ten or more i'ears after replacement showed sublu-xation and deformation 
of the head in most of the cases. He believes that everj' dislocation should be kept 
under x-ray control until adolescence. 

Prof. Frejka emphasized the need of training the medical profession to treat dis- 
locations as early as possible, — at the age of one and one-half years at the latest. The 
teaching that results will be equall3' successful after the second j^ar encourages delaj" in 
reposition. He demonstrated the good results obtained bj' detorsion operations in 
which he used Zahradnfcek’s method, which he prefers to the simpler shelving operation 
without reposition and without adjustment of anteversion. He showed several cases of 
operative replacement bj’ the Zahradnicek method. 

Dr. Pavlansk^' discussed the necrosis of the head which occurs in the course of non- 
operative treatment, and showed that this is frequent after non-operative replacements, 
particularl3' when the luxation is high. After operative replacement and detorsion os- 
teotom3', he had not obsen^ed necrosis of the head. In Prof. Zahradnfcek’s Clinic, 
cases are treated non-operatively up to the age of three or three and one-half, and, after 
the third 3'ear, b3’ operation. Necrosis of the head is thought to be the result of ischaemia 
arising from strain of the capsule at the time of the reduction. 

There was also discussion b3' Prof. Mikula, Dr. Janek and Dr. Mestric, Dr. Alberti, 
Dr. Delic, Dr. Vlasic, and Dr. Ambrozic, who gave their experiences with the treatment 
of this disorder. 

The second main subject dealt with was “War Injuries of Bones and Joints”. Dr. 
Florschtits spoke of methods of treatment, and Dr. Danic placed the blame for the bad 
results during the War on the organization of the work, and emphasized the necessit3' of 
these cases being in charge of and treated b3' men of experience. 

Papers were presented b3' Prof. Zahradnicek on his operation for spond3’lolistlic.sis 
and b3^ Prof. Frejka on infantile k3'phosis. Prof. Spisic sliowed a film on the treatment 
of contractures of articulations ly plaster bandages and the Quengel method. Dr. Janek 
spoke of the significance of the gonococcus reaction in articular diseases. Dr. Jovcid 
demonstrated the results of reductions of traumatic dislocation of the hip. Dr. Grospic 
showed slides to illustrate the results of plastic operations on the knee, the hip, and the 
elbow. Dr. Delic spoke on spine grafting, and stated that in the most severe cases of 
thoracic gibbosit3' he uses a solid bone graft introduced above or below the gibbosit3’ 1)3- 
transversectom3'. Dr. Stojadinovic demonstrated the results of treatment of c3-sts of the 
bone. Dr. Savic showed slides to illustrate the results of operative replacement of old 
dislocations of the shoulder and the elbow. 

The Congress closed with a reception at the Belgrade Aero-Chib. The next Con- 
gress will take place in Prague carh- in Juh’ 193 S, at the same time as the Pan-Slavonic 
Medical Congress and the Pan-Sokol Raill.v. The principal subjects will be “P.-eudar- 
throsis”, to be discus.sed b3' Prof. Zahradnicek, and “Necrosis of Bone”, Iw Dr. Frejka. 


BRITISH ORTHOPAEDIC ASSOCIATION 

The .\nnual Meeting of the British Orthopaedic .-Xssociation was held in .Slieincld 
on October 29 and 30 under the Prcsidenc3’ of Mr. W. R. Bri.stow. A largo number of 

VOL. XX. NO. 1. J.\XV.VUY IMS 



236 


NEWS NOTES 


iiitertroclianteric osteotomy wliich preserves intact tiie musculature and leaves the ab- 
ductors attached to the ti-ochanter. 

The remainder of the Congress was devoted to the presentation of the following 
papers : 

Vertebral Aspects of Paget’s Disease — Dr. Charles Lasserre, of Bordeaux. 

Blood Chemistiy in Various Diseases of Bone — Dr. Charles Lasserre and Dr. L. 
Servantie, of Bordeau.x. 

Slipping of the Patella— Dr. Guilleminet and Dr. Brunat, of Lyons. 

Correction of Scoliosis by Plaster Cast — Dr. Lucien Michel, of Lyons. 

Chondrodystrophy with Widening and Flattening of the Vertebrae (Platybrachy- 
spondjdia) — Dr. R. Guei’in and Dr. P. Lachapele, of Bordeaux. 

Congenital Luxation of the Atlas through Malformation of the A.xis — Dr. Lom- 
bard and Dr. Le Genisscl, of Algiers. 

Infantile Kyphosis — Prof. Frcjka, of Brno. 

Fractures of the Upper End of the Radius, with a Report of Seventeen Cases— 
Dr. H. L. Rocher, of Bordeau.x. 

Arthroereisis with “Os Puruin” — Dr. P. Marique, of Brussels. 

Drilling of the Neck of the Femur in Arthritis Deformans of the Hip — Dr. R. 
Chany and Dr. G. Chany, of Toulouse. 

Roentgenography of the Articulations — Dr. F. Pouzet, of Lyons. 

Tibia Vara — Dr. Pouzet, of Ljmns. 

Astragalectomy — Dr. Petrov, of Sofia. 

Congenital Deformities — Dr. Nicod, of Lausanne. 

Deformities of the Menisci of the Knee — Dr. Dieterich, of Mulhouse. 

The next Congress will be held in Paris on October 7, 1938, at the Facidti de Midecinc 
de Paris, under the presidency of Prof. H. L. Rocher, of Bordeaux. The subjects to be 
discussed are: “Painful Vertebral Kj'phosis Due to Dj'stropliy “ and “Simultaneous 
Fractures of the Shafts of Both Bones of the Forearm”. 

The Society will visit the orthopaedic centers of the important cities of Switzerland 
at the end of September 1938. 


The Congress of the Yugoslavian and Czechoslovakian Orthopaedic Societies 
was held in Belgrade, on October 18 and 19, 1937. Prof. Dr. Rocher of Bordeaux, Prof. 
Dr. Gruca of Lwow, Poland, Pi'of. Dr. Raszeja of Poznan, Poland, and Prof. Dr. Boicev 
of Bulgaria, were present as guests, and there were representatives from all the Slavic 
countries except Russia. The principal subject of discussion was “Congenital Dislo- 
cation of the Hip”. 

Docent Dr. Jovcic called attention to the prevalence of congenital dislocation of the 
hip in Yugoslavia and estimated that there were about 30,000 cases in his country. He 
reported that, in a total of 900 cases which he had treated, the best results had been 
obtained in patients under two years of age, both anatomical and functional results at 
this period being 100 per cent, successful. Correct replacement and treatment by the 
use of plaster bandages require I'eal skill and should onl}'^ be attempted by those who 
are highlj^ experienced. 

The second speaker. Prof. Zahradnicek, presented the operative treatment of t iis 
luxation. He regards subtrochanteric osteotomy of the Kirmisson-Lorenz-Schanz type 
as an erroneous procedure, which should be used onl}’’ when the anatomical changes arc 
of too pronounced a character or when the patient will not agree to a radical opeiatiom 
The radical operations performed in Prof. Zahradnfeek’s clinic are of three types, l 
operative replacement without shortening of the femoral bone, either witli or u it lou^ 
the shelf operation (this method is suitable mainly for small children in wliom no 
much shortening takes place and the soft parte, notably^ the articular capsule, presen^ 
an anatomical obstacle to replacement); (2) operative replacement and shortening 
the femoral bone, with the shelf operation, which is necessary in lu.xations witii (on 

THE JOURNAL OF BONE AND JOINT SURGLR' 



NEWS NOTES 


239 


Some Principles of Joint Mechanics by Mr. M. A. McConaill, Sheffield 

In a most stimulating resume, Mr. McConaill presented his views on joint me- 
chanics derived from six years of anatomical investigation. He maintained that the 
chief function of the specific sjmovial fluid is to prevent friction, — a function which is 
least active during the full coaptation of the joint surfaces in weight-bearing. Hence 
degenerative changes occur most frequentlj' on those surfaces which fit together best. 
The ligaments are not elastic and are so arranged that they act to prevent the harmful 
effects of torsion. Mr. McConaill’s thesis was new to many members of the Association 
and it evoked much enthusiastic interest. It is to be hoped that his work will be avail- 
able in written form later. 

Some End Results of Bone and Joint Tuberculosis by Mr. J. C. Scott, O.xford 

Mr. Scott presented a preliminary report o'f an end-result survey of 5S2 patients 
suffering from tuberculous disease of the spine and of the hip joint. As far as possible 
the results of conservative treatment alone were contrasted with those in which con- 
servative treatment had been reenforced by operative measures. The combined pro- 
cedure appeared to have a slight advantage. 

Certain Injuries of the Carpus by Mr. J. L. Grout, Sheffield 

Mr. Grout reported his findings in an .x-ray investigation of the wrists and hands 
of some thirty-nine workers who use pneumatic drills and chisels. In a little less than 
half of the men, small cystlike spaces, giving rise to no symptoms, were found in the car- 
pal and metacarpal bones. No e.xplanation of these cysts is available at present. 
Osteo-arthritis of various joints was a common finding. 

The Early Diagnosis of Malignancy in Bone Tumors by Dr. J. F. Brailsford, Birmingham 
Dr. Brailsford gave for the most part an excellent resume of the present-day atti- 
tude in relation to the diagnosis and treatment of malignant bone tumors. He empha- 
sized the difficulties in diagnosis in general, and of x-ray interpretation in particular. 
In doubtful cases he prefers to be guided by serial roentgenograms, and he differs sub- 
stantially from his surgical colleagues in condemning the routine use of biopsy. If the 
latter is used, the area selected for the removal of tissue should be determined with 
precision beforehand bj" the roentgenologist. Dr. Brailsford made a strong plea for 
closer cooperation between the clinician, the pathologist, and tlie roentgenologist. 

Nephrolithiasis Occurring in Recumbency by Mr. R. Guy Pulvertaft, Grimsby 

The cases of sixty patients, who, during long periods of immobilization in recum- 
bency for tuberculous bone or joint lesions, had developed renal calculi, were reviewed. 
The factors responsible for stone formation appear to be defective renal drainage and the 
wide-spread skeletal and muscular decalcification. Preventive measures consist of fre- 
quent “turnings” of the patient, avoidance of excessive e.xposure to the sun, and a gener- 
ous fluid intake. A minority of stones require operative removal. The majority are 
passed as “gravel” when “turnings” are commenced or when the patient becomes 
ambulatory. 

Arthrodesis of the Hip by Mr. R. Watson Jones, Liverpool 

The technique of intra-articular arthrodesis, followed some ten days later by the 
“closed” introduction of a long Smith-Petersen nail along the femoral neck deeply into 
the ilium, was described. It was claimed that the combined procedure had greatly 
increased the chances of securing bony union. The excellent re,sults achieved were 
demonstrated in a ver 3 ’ instructive film. Mr. Watson Jones referred briefl\' to the 
method, still on trial, of fi-xing the osteo-arthritic hip Iw a long Smith-Petersen nail in- 
troduced through a short incision without a preliminary denudation of the articular 
surfacc.s. This procedure obvioush' i.s more applicable to older people than is the rorn- 
bined operation, and the rc.sult.s so far have been cncouniging. 


voi.. XX, xo. 1. j.ixo.vnv ip.is 



238 


NEWS NOTES 


members and guests were present and enjoyed a most stimulating program. Tlie Asso- 
ciation Dinner was held at tlie Royal Victoria Hotel. The guests included the Chairman 
of the Royal Infirmary and the Vice-Chairman of the Children’s Hospital, as well as 
many distinguished members of the University and Hospital Medical Staffs. Prior 
to the dinner, visits to one of the large steel works and to a coal mine had been most 
interesting interludes in the scientific proceedings. 

The scientific program wms divided into two parts, as follows; 

I. A Clinical Demonstration w'hich was given in the Out-Patient Department of 
the Sheffield Royal Infirmary. Many patients illustrating the results of treatment of 
fractures and of diseases and neoplasms of the locomotor system were shown by Mr. 
S. W. Daw, of Leeds, and Mr. J. B. Ferguson Wilson, Mr. C. Lee-Pattison, Mr. Arthur 
M. Connell, and Mr. F. W. Holdswoi’th, all of Sheffield. 

II. The Presidential Addi'ess and a series of short papers which occupied two 
mornings at the Medical Library of the Univei-sity. 

Orthopaedic Svrgeri/ — Retrospect and Forecast by Mr. W. R. Bristow, London 

The President traced the post-war growth in Orthopaedic Surgery which had 
proceeded pan passu with specialization in other surgical fields. Decentralization 
w'as increasing, especially in orthopaedic surgery, and was causing the university hos- 
pitals some difficult}'' in obtaining representative clinical material for the purposes of 
student teaching. It was suggested that this difficulty might be overcome by closer 
cooperation between city and country hospitals. The Pr-esident also outlined the changes 
which w'ould have to take place, as a result of multiple special departments, in the cur- 
riculum of the student during his hospital training so that he could have practical ex- 
perience in each branch of Surgery. 

Treatment of Minor Injuries by Mr. W. G. Campbell, Dundee 

A detailed account was given of the early treatment of strains of ligaments and 
muscles by the injection of a local anaesthetic into the site of tenderness. It was as- 
sumed that Leriche’s conception of strain is the right one, — namely, that there is no 
tearing of ligamentous fibers, but apparent impulses passing from the “jiamaged” area 
begin a vicious circle of local vasodilatation, metabolites, etc. In a comparative senes 
of patients Mr. Campbell found that treatment b}' this method had resulted in cure in 
about three days, as compared with twelve days by the conventional method of strap- 
ping, etc. 

The Correction of Spinal Kyphosis by Means of a Continuously Adjustable Bed by Mr. 

R. W. Butler, Cambridge 

With diagrams and a model, Mr. Butler demonstrated in detail how to make and 
to use his ingenious sectional plaster-of-Paris bed for the correction of anteropostenoi 
deformities of the spine. 

Ossification of Ldgaments of the Elbow Joint by Mr. St. J. D. Buxton, London 

The frequency of ossification in the ligaments following injuries, especially dis o- 
cations, was stressed. It was emphasized that the amount of ossification is governce 
largely by the treatment of the injured joint. If rested for an adequate period (severa 
weeks), no harmful amount of ossification results, but if efforts are made early to oic 
movements, then extensive new bone formation often occurs and the mobility o ic 
joint is seriously restricted for all time. 

Undulant-Feoer Osteitis by Prof. Green, Sheffield 

A most interesting review of the literature on this rare fever was presented and vaii- 
ous features of it demonstrated from the records of a patient under Prof. Green s care. 
Bones and joints are frequently involved and abscesses form which usual y reso ' ^ 
quickly without persistent sinuses. The roentgenographic changes in the bony lesion 
are not typical and may resemble those seen in tuberculous disease. An 'y osis 
joints is rare and the general prognosis is good. 

THE JOURNAL OF BOXE AND JOINT SUROKR' 



SCOMO.SIS TKKATKD I3Y THE WEDGING JACKET 


7 


up tlio third luinlmr vi'rtrlirn in llio niarkor rocntgonogram (Fig. 3) on the 
fourth in tlio iielvic-tilt o.xamination (Fig. 2). The patient is normally 
active and has no .'Symptoms referable to the spine. Her shoulders are 
level, and the head and trunk are well eentered over the pelvis. 

Co.sT 2 {Figures o, G, 7, (uid S) 

L. C. T., female, aged fourteen years, had an “idiopathic" scoliosis, 
the jirimary riglit eurve extending from the fifth thoracic to the first lum- 
bar vertebra with the ajiex at the ninth thoracic. She had had jacket cor- 
rection and spine fusion three and a half j’^ears before admission to this 
Clinic. Figure 5 shows that the fusion area did not include the whole of 
the jirimary curve, but stojiiied below at the eleventh thoracic, and that 
pscudarthroses were present at four joints in the area operated upon, — ■ 
the fourth thoracic to the eleventh thoracic. The deformity obviously 
had increased or recurred within the area operated upon and at the joints 
within the primary curve which had been omitted, — the eleventh thoracic 
to the first lumbar. 

A pelvic-tilt examination was made, the patient sitting with the left 
side of the pelvis elevated (Fig. 6). This showed excellent straightening 
at each of the joints in the lumbar spine, and justified the expectation that 
the same thing would occur in proper degree after correction and fusion 
of the primary thoracic curve. 

After jacket correction was obtained, the spine-marker roentgeno- 
gram (Fig. 7) was made. This shows the position in which the spine is to 
be fused. To fuse the minimum area — the extent of the primary curve 
(the fifth thoracic to the first lumbar) — might give a satisfactory result, 
but to extend the fusion one vertebra above (to the fourth thoracic) and 
one vertebra below (to the second lumbar) would give a more nearly ideal 
result, because the end vertebrae of the fusion would be parallel to each 
other and transverse to the axis of the trunk. One may choose to extend 
the minimum fusion to form this ideal area provided that the unfused por- 
tions of the spine above and below, and particularly below, are capable of 
complete spontaneous straightening under their own muscle power. Al- 
lowing for slight loss during the first year after fusion, it will be seen in the 
present case that the lower surface of the second lumbar vertebra (dotted 
line. Fig. 7) will be transverse to the body axis and should sit squarely 
upon the upper surface of the third lumbar when the latter has straight- 
ened to the position shown in the pelvic-tilt examination (dotted line. 
Fig. 6). A superimposition of the third lumbar in the marker roentgeno- 
gram on the fourth lumbar in the pehdc-tilt examination will obviously 
not give a good total alignment. In December 1932, the previous fu- 
sion was extended to include the second lumbar vertebra and the four 
pscudarthroses were found and repaired, making the total fusion area 
from the fourth thoracic to the second lumbar vertebra. 

Figure 8, taken three and a half years later, shows the fusion to be 
solid throughout and the total alignment to be excellent. Considerable 


VOL. XX. XO. I. JAXUARY 19.LS 



Current Literature 


The Management oe Fkactures, Dislocations, and Speains. John Albert Key, 

B.S., M.D., and H. Earle Conwell, M.D., F.A.C.S. Ed. 2. St. Louis, The C. V. 

Mosb}’^ Co., 1937. S12.50. 

This new edition is lai'ger and more attractive than the first. Again the authors 
have produced a book which is a good working guide for the surgeon, practitioner, or 
student. The same arrangement as in the first edition — Part I : Principles and General 
Aspects; and Part II: The Diagnosis and Treatment of Specific Injuries — is retained. 
Many chapters have been slightly altered; there arc some new illusti’ations, and, in cer- 
tain places, better illustrations have been substituted. 

As in the previous edition, thei’c are excellent and unusual chapters dealing with 
the Workmen’s Compensation Law as it affects fracture cases and the medicolegal 
aspects of fracture cases. 

The chapters on “Fractures of the Skull and Brain Trauma” by C. E. Dowman 
and “Fractures of the Jaws and Related Bones of the Face” by J. B. Brown have been 
rewritten. The alterations in the latter chapter are the most radical in the book. The 
illustrations in this chapter are numerous and excellent and the text shows evidence of a 
great deal of careful study. 

Injuries of the spine are discussed from the point of view of today’s treatment. 
Much has been added in regard to the treatment of compression fractures. A discussion 
of rupture and herniation of the intervertebral discs, a subject of much interest and con- 
cern at the present time, has been included for the first time. However, fourteen lines 
with no illustrations seems like an inadequate presentation of such an important subject 
in a chapter of ninety-four pages on spine injuries. 

Tliis book is very interesting. The e.xperiences of the authors seem to dovetail 
very niceljL Wherever there is a difference of opinion or in technique, both opinions are 
given. This second edition contains no revolutionary changes, but represents a moderni- 
zation of the previous volume. 


Table GiiNlliRALE des Annees 1908-1932 du Journal de Chirurgie. Etablie par 

J. Dumont et P. Grisel, avec la collaboration de M'"'* J. Dumont. Paris, Masson et 

C‘®, 1937. 260 francs. 

This book is an index of the original papers and articles abstracted in the fiist 
forty volumes of Le Journal dc Chirurgie. This material has not been classified ac- 
cording to the usual alphabetical order, but according to the subject matter, as is the 
custom in the monthlj'^ issues of this publication. The references are first arranged undei 
general headings such as "Surgical Pathology”, “Skin”, “Cartilage”, “Bone ’, Mus 
cles”, etc., and subdivided, and then they are grouped under regions with their s^uc 
tures. In this way is made easily available all of the material which has been publis ic 
in these forty volumes with reference to a particular subject. The references aicai 
ranged chronologically'^ according to the volume in which they appeared. 

As an added convenience, the editors have placed at the beginning of the vo umc 
an index of the original articles arranged alphabetically according to the authois. 

As is explained by Dr. Grisel in the Foreword, the index covers the abstiacts rom 
April 1, 1908, to December 1, 1932, but it includes the original articles up to December 
1935. 

This book should be a valuable addition to the physician’s reference libiaij- 


The Thinking Body. A Study of the Balancing Forces of Dynamic Man. 

Elsworth Todd. New York, Paul B. Hoeber, Inc., 1937. S4.00. .-x, i I ora- 

After many years of practical experience and special study combined vi i 
tory investigation, Miss Todd has presented her original views on this genera su j 

240 the journal of bone and joint suroeb 



CURRENT LITERATURE 


241 


of physiotherapy. This work is considered through quite a new approach, and the 
author carefullj' avoids any claim to a school or system but aims to present, more or 
less originally, the principles involved in utilizing the coordination of the related functions 
of the body. As its title indicates, the book is not a treatise dealing with the conven- 
tional acceptation of the subject of physiotherapy, but represents the result of an indi- 
vidual study and investigation of the physical and p.sychological influences which un- 
derlie body development. 

From the beginning of her work on this particular form of therapy, the author em- 
phasizes the value of the coordinating movements and the necessity of understanding 
and cooperation on the part of the patient. One of the principal objects of the book is 
to aid those who are engaged in the practice of physiotherapy to obtain body balance 
in such a way that it may be a factor in daily life and correct the ill effects which result from 
body imbalance. The author wisely emphasizes the influences which are attributable 
to psychology and gives to them more prominence than is usually found in textbooks 
dealing with this subject. She emphasizes the necessity of a thorough understanding 
of anatomy, physiology, and nerve control in order to appreciate the important part 
which they play in the movements of the body. This forms the basis on which her 
theories are founded and put into execution. 

The special functions, such as breathing, walking, etc., are analyzed in detail. 
Posture, both normal and defective, is given adequate consideration, and the discussion 
of the principles of correction of posture defects and the methods of accomplishing this 
correction will be found to contain much that is original. The skeletal and muscular 
sj'stems and their combined action in the development and maintenance of the normal 
body balance are given special prominence, with a ver 3 ' full discussion of the fundamental 
role which they plaj', as well as the importance of their coordination. 

In this unique presentation, the reader will find much to interest and to aid him 
in the performance of his dailj' work, even though he may not always agree with all of the 
theories and practices. 


Physical Therapy in Arthritis. Frank Hammond Krusen, M.D. Foreword b^’ Mel- 
vin S. Henderson, M.D. New York, Paul B. Hoeber, Inc., 1937. .S2.25. 

Arthritis has been termed the “stepchild” of Medicine, but there can be no step- 
child without a step-parent. The author has commendabli' applied him.self to the 
preparation of this little book, primarilj' as a guide for the general practitioner. Tliis 
appears to have been done with a realization of the fact that insufficient familiaritj' with 
the possibilities of physical therapy and with its technique arc largelj' responsible for 
the defeatist attitude often assumed bj' the phj'sician. Having disposed of foci of in- 
fection as well as may be and having cmploj’cd various drugs and sera, he finds that 
arthritis stilt remains to be treated. In this situation, he is onlj’ too often found unin- 
formed regarding the applicability of the various methods to the case in quc.stion, or 
under the mistaken impre.ssion that thej' arc available onlj' through institutional care. 

To the author’s credit it must be said that he has succcssfullj- striven to give a more 
correct conception of the situation to the reader. His descriptions arc clear and well 
suited to the compendious form which he has chosen. Perhaps it maj’ be .“aid that, in 
his desire to give credit to those who have contributed to the literature of the .subject, 
his text abounds in a superfluity of quotations which does not add to its claritj’, espe- 
ciallj’ since the complete references are al.so given. While the various methods in use 
are sufficientlj’ described, there is an admirable lack of e.xcosive omph.asis upon the 
need for those who.se value is not genendl.v accepted. It mu't be admitted, however, 
that in a number of instances methods and appanitus arc portrayed whose cmploi’ment 
would be precluded in an.v but the more commodious homes or wcll-e<|uipped institutions. 
This but emphasizes the fact that, while tho'C arthritics who have abundant means mav 
and do engage in the elusive search of a climate which will cure them and the services 
of well-staffed institutions, there is a genend and unfortunate paucity of pnivision for 


VOL. NX. NO. 1. JANTARY ISIS 



242 


CUItUENT LITERATURE 


sufficiently extended care of those in less fortunate economic situations. It would seem 
difficult to agree, without considerable qualification, with the author's final sentence: 

“With a little ingenuity the fainil 3 ’^ phj'sician can suppl 3 '^ nearly all the necessary 
phj'sical therapy' in the patient’s own home.’’ 


Beitrag zur Kenntnis der angeborenen’ Huftgelen'ksverrenkung (A Contribu- 
tion to Our Knowledge of Congenital Dislocation of the Hip). Dr. Max Rene 
Francillon. (Beilageheft zur Zeitschrift fiir Orthopiidie, Bd. LXVI.) Stuttgart, 
Ferdinand Enke, 1937. 9.80 marks. 

One hundred and ninety'-si.x cases of congenital dislocation of the hip were reviewed 
primarily' in the interest of “ ischiometric ’’ deteiuninations. In the course of the follow-up 
examinations, a critical study' of the end results furnished interesting data. These, with 
comparative studies from other sources, have been e.vpanded to form a comprehensive 
monograph. 

The ratio of eight females to one male, instead of the usual six to one, is explained 
on anthropological grounds. The accurate diagnosis and prognosis in the luxated hip, 
and particularly' in the subluxated hip, entail careful study of the development and 
position of the osseous center of the head, of Shenton’s (better Menard’s) line, and of 
the degree of ossification of the ischiopubic synchondrosis. Both the developmental and 
the mechanical factors in the causation are variables. 

Retarded development is evident in the delay'ed ossification of the ischiopubic 
sy'nchondrosis, the os acetabuli superior, and the osseous center of the femoral head; as 
well as the persistent anterior torsion of the femur. The retroversion and shape of the 
femoral head are discussed. An extensive review of the frequent osteochondral lesion 
of the head leads to the conclusion that it is a peculiar j’eaction of the bone (probably' with 
several exciting causes) and not a specific disease. 

“Ischiometric” detezminations as suggested by Schez’b are z-ecoz-ded in three cases 
to illustrate how this clinical-znathematical observation supplements the roentgeno- 
gz’aphic findings in determining the shape of the femoral head and the condition of the 
joint cartilage. 

Detailed anatomical studies are well illustrated. 


Tissue Reactions in Bone and Dentine. A Morpho-Biological Study of the 

Formation and the Dissolving of Bone and Dentine. Ake Wilton, M.D. 

London, Henry Kimpton, 1937. 

This 194-page book reflects a gi'eat deal of meticulous woz'k and serious thought on 
the subject of deteimination and diffei’entiation in bone and dentine. The pi’esentation 
is clear and scholarly. There are many good illustz’ations, of which several are in coloi. 
A comprehensive bibliography is appended. . . 

The author’s own investigations, consisting of nine years of careful histologica 
study of the normal and the pathological development of bone and dentine, are recountc 
after a complete review of the literature. The authoz' has introduced to the subject i\ la 
he terms an “N-factor”, which bz'ings about abnormally' slow differentiation and decrease 
in growth, acting generally on the tissues of the connective system, and most stzozigy 
where the rate of growth is greatest. The skeletal deformities in rickets and achon ro 
plasia are thought to be caused by the action of this N-factor on the normal endoclionc ra 
ossification. By comparative studies of the arrest of development of cartilzigc, zozie^ 
and teeth in achondroplasia, the N-factor is shown to act during foetal life in invers 
proportion to the degree of deteimination and diffez-entiation of the tissues. 

The author has made a study of osteolysis in expezlmental osteitis fibrosa ® 
scurvy', Paget’s disease, osteogenesis imperfecta, senile osteoporosis, and the dis.so u lo^ 
of transplanted bone grafts. The author has found that vitamin-C deficiency pro tz^^ 
an abnozmal dedifferentiation with abnormal proliferation of the dentine an zo 

THE JOURNAL OF BONE AND JOZNT SUaGLRl 



CURRENT LITERATURE 


243 


and considers the scorbutic dentine alterations in guinea-pigs clear proof that a tissue 
ina 3 ' grow — that is, increase its number of functioning tissue elements — bj- dedifferentia- 
tion of previouslj’- differentiated cells. During healing, redifferentiation takes place. 
In Paget’s disease it is shown that osteolj’tic foci arise bj" dedifferentiation of differentiated 
bone cells (osteocjdes). Giant cells and a granulation-like tissue (Virchow’s tissue) then 
arise to proliferate into the atrophic periosteum. On redifferentiation, bone formation 
occurs outside the original compact, and, bj' repetition of the process, increase in breadth 
takes place. In osteogenesis imperfecta, osteolj’sis occurs as in scurvj^ in the main, and 
alterations are most pronounced in the parts most highlj’ differentiated (tuber parietale). 
The alterations in scurvj’ and osteogenesis imperfecta are presumed to be produced bj' 
what the author calls a “W-factor”. He defines this factor as one which brings about 
abnormal dedifferentiation with abnormal increase in growth, acting general^^ on the 
tissues of the connective sj’stem and most strongl 5 ' where the rate of growth is least. 
Consequentlj', the “N” and “W” factors stand in a certain antagonistic relation to 
each other. Thej^ have nothing to do with the real genesis of the diseases, however. 
The prevailing classifications of bone resorption are discussed, and reclassification is 
suggested under the headings: active, passive, and lingering resorption. 

This book is highlj' recommended to all who are interested in the pathological 
phj’siologj’ of bone and teeth. 


Chronic Rheumatic Diseases: Being the Third Anmual Report of the British 
Committee on Chronic Rheumatic Diseases Appointed by The Royal Col- 
lege OF Physicians. Edited bj' C. W. Bucklej', M.D., F.R.C.P. New York, 
The Macmillan Co., 1937. 

This third report of the British Committee is well up to the standard of the other 
two volumes and brings out many points of interest for the student of rheumatic 
diseases. 

The first chapter is a summarj' of the evidence against vaccine therapj'. Sj'mpa- 
thectomies are discussed with the following conclusion: So long as the cause of the disease 
remains unknown, operations on the sj’mpathetic sj'stem should be regarded as purelj' 
sj'mptomatic treatment, not as direct treatment of the disease. There is an e.vcellent 
paper on x-raj’ therapj'. The best results are obtained in inflammatorj' processes of the 
joint capsule and in periarticular inflammations. The newer knowledge of avitaminosis 
in rheumatoid arthritis shows that vitamin A and vitamin C in the serum are subnormal. 
Vitamin B is probablj' deficient as well, but this has not j’et been demonstrated. In the 
chapter on chrj'sotherapj', the author concludes that, in the present state of knowledge, 
tliis form of therapj' is of value in rheumatoid tj'pcs of arthritis. There is an excellent 
chapter bj' Hench on recent investigations of disca.'es of joints and related structures 
in America, with a profuse bibliographj'. 

The book gives one a great deal of food for thought and the sense that progres.s in 
the treatment of chronic rheumatic diseases is being made. It is well worth careful 
studj'. 


Carcino-Osteogenic Sarcom.^ — A Malign.^nt Mixed Tumor of the Chest Wall: 

Report of a Case. J. W. Budd and Frank J. Bre.slin. T/ic Amcricftn Journal of 

Cancer, XXXI, 207, Oct. 1937. 

The authors report a tumor occurring in the subcutaneous tissues ju.st above the 
breast in a woman of fiftj'-ninc. This tumor had been present for manj' j'cars and grew 
rapidlj' for a j'ear before operation. Following local removal, the patient ha.s remained 
well for four j'cars. Numerous photomicrographs illustrate the extraordinarj- pathologj- 
of the tumor, consisting in nipidlj' growing neopl.astic epithelium and osteogenic tis.mc. 

It seemed probable to the authors that there had been a sarcomatous transformation 
of the connective-tissue stroma of the carcinoma and that this .sarcoma had assume<i 
osteogenic properties. — Granllc;/ IF. Taylor, .17./?., lio'^ton, MaaraciiuffUf. 


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CURRENT LITERATURE 


The Coukelation' between Sebum Phosphatase anb Roentgenographic Type ix 
Bone Disease. Helen Quinby Woodard and Norman h. Higinbotham. The 
American Journal of Cancer, XXXI, 221, Oct. 1937. 

The authoi's have continued their studies on serum piiosphatase and report in detail 
their findings in 203 jiersons with normal, benign, and malignant bone conditions seen at 


the Memorial Hosjiital. In general these findings confirm the conclusions reached in 


tlieir earlier paper, — namely, that .serum phosphatase is an indication of the amount of 
new bone formation taking jilace in the body, or of the attempt on the part of the body to 
form new bone, and is a measui'e of the functional rathei' than the histological type of the 


disease. 

The paper presents detailed tables of the cases of primary and metastatic malignant 
tumors, with the determinations carried out in them. 

The authors draw the following conclusions: 

1. If a high serum phosphatase is found associated with an osteoplastic lesion or a 
normal serum phosphatase with an osteolytic lesion, then the phosphatase determination 
has served onlj' to confirm the diagnosis made bj’’ the roentgenogram. 

2. If a normal serum phosphatase is found as.sociated with an osteoplastic lesion, 
then the pi-ocess is probably slow gi-owing and relatively benign. 

3. If a high serum phosphatase is found associated with an osteolytic lesion, 
several possibilities present themselves: 

a. The case ma 3 ’' be one of hj’^perparathymoidism. If this is so, the serum cal- 
cium and inorganic phos]jhoru.s will nearh' always be abnormal and will 
serve to establish the diagnosis. 

b. There may be osteoplastic disease elsewhere in the bodj'^, which will account 
for the high serum pho.sphatase, even though the presenting lesion is oste- 
olytic. 

c. The case may' be one of a group made up chiefly' of endotheliomata or car- 
cinomata of diverse origin, metastatic to bone, which raise the serum- 
phosphatase level, but for some unknown reason do not form new bone. 
The presence of an elevated serum phosphatase may serve to distinguish 
these lesions from various types of benign osteolytic disease, which very sel- 
dom raise the serum phosphatase. 

d. The case may' be one of an early highly' malignant osteogenic sarcoma. Sonw 
of these fail to show new bone formation, probably' because their very rapid 
growth rate outstrips the relatively slow deposition of calcium phosphate. 
Such tumors may show osteoplasia later in the course of the disease. In 
these cases the association of a high serum phosphatase with a rapidly grow- 
ing osteolytic lesion probably indicates a high degree of malignancy. 

4. Follow'-up determinations of the serum phosphatase in cases w'ith an initially 
elevated phosphatase may predict the development of metastases after the extirpation 
of the primary tumor, but cannot be depended on to do so. 

5. Determinations of serum phosphatase in cases of bone tumors which have been 
treated by roentgen or gamma rays are useful in indicating the degree and permanence 
of the inactivation caused by irradiation. 

6. While the presence of a normal serum phosphatase gives no assurance that lone 
disease is absent, the presence of a persistently' elevated serum phosphatase in a paticn^ 
who is not jaundiced and W'ho is not under treatment with Coley'’s toxins is a very 
strong indication that bone disease is present and should nevei' be disregarded. Gran cij 
ir. Taylor, ]\f.D., Boston, Massachusetts. 


Trauma as a Factor in Pott’s Disease. Max H. Skolnick. The American Rciicu of 
Tuberculosis, XXXVI, 429, Sept. 1937. ^ 

That trauma has a definite relationship to later development of Pott s isca- 
brought out by the author. Considerable time may' elapse between the trauma aru 

THE JOURNAE OF BONE AND JOINT SUnGI.Ii 



CURRENT LITERATURE 


245 


development of active disease, and the slighter forms of trauma seem to be a greater 
causative factor than severe injuiy. Symntomatologj' pla3's the most important part in 
the earlj' diagnosis. Considerable time is required for such lesions to become clinicallj' 
and objectivelj’' manifest, but if roentgenograms were taken in ever3' case where s3mipto- 
matolog3' indicates possible activit3', man3’’ cases would be discovered before irreparable 
damage had resulted . — Clarence A. Ryan, M.D., Vancouver, B. C., Canada. 


Internal Fixation in Fractures of the Neck of the Femur. Willis C. Campbell 

Annals of Surgery, CV, 939 , 1937 . 

The author states that there are three t3’pes of fractures of the neck of the femur. 
The intracapsular or complete central t3'pe comprises about 43 per cent, of these frac- 
tures. It is in this t3'pe of fracture that non-union so frequentl3' occurs. In the im- 
pacted and intertrochanteric t3’pes union can be expected in 100 per cent, of the cases. 

The causes of non-union are impaired circulation to the proximal fragment, osteoporo- 
sis, inaccurate reduction, the sheering action of weight-bearing, the deleterious action 
of the joint fluid, and deficient blood clot. Lateral roentgenograms aid in determining 
whether or not a reduction has been accomplished. 

For the treatment of the intracapsular t3'pe, Whitman in 1904 published his abduc- 
tion piaster-fixation treatment b3’ which union can be secured. In a surve3’' made b3' a 
committee appointed b3’- the American Orthopaedic Association in 1929 it was found that 
in 50.4 per cent, of 201 cases selected from well-known clinics bon3' union had been se- 
cured b3" the 'ttfliitman method in the complete central or intracapsular t3'pe of fracture. 

The author was an adherent of the Whitman procedure, but now believes that in- 
ternal fixation gives a higher percentage of excellent functional results and bon3’' union, 
and decreases the time of non-weight-bearing from six to twelve months to four to six 
months, with less damage to the knee and hip joints. The author emplo3’s blind nailing, 
using the Smith-Petersen nail, and has so treated thirt3’-five cases of the intracapsular 
type. 

A follow-up report of these cases is included in detail. The operative technique is 
described and illustrated. — Al T. Kirk, M.D., San Francisco, California. 


The Regeneration of Bone Transplants. Hans AIa3'. Armais of Surgery, CVI, 441 , 

Sept. 1937 . 

A review of the literature on this suliject is presented and the autlior describc.s his 
own research as follows. 

An investigation directed to the process of vascularization of a hone graft was carried 
out b3’ subperiosteall3' removing the radius (including its two articular ends), placing the 
removed bone in salt solution and then replanting it in its original bed, and suturing the 
periosteum and closing the joint capsules. Twent3'-fivc such experiments were per- 
formed on dogs, but aseptic healing occurred in onh' four animals. X-ra3's were made 
eveiy eight da3’s. The dogs were killed after five weeks, ten weeks, four months, and 
ten months, followed immediateh' in eacli case 1)3- injection of tlie axillar3- arter3' with a 
turpcntine-mercur3' solution. The radii were removed, .x-ra3'ed, and studied liistologi- 
calR- with the following findings: 

The graft alwa3’s dies after transplantation; man3’ nucleii di.sappear, others de- 
generate, but in from two and a half to four months regeneration occurs 1)3- creeping sub- 
stitution of dead bone 1 ) 3 - new bone. Small and large ve.ssels grow from the periosteum 
into the graft; the former earh’ regre.ss as the large ve.s.sels progre.-.s until the entire graft 
is supplied b3' a well-arranged vascular si-stcm. That part of the graft not covered 1 ) 3 - 
periosteum becomes dostro3-ed 1)3' ingrowing fibrous tissue and onh' small iwrtions are 
saved b3' surviving osteoblasts. The periosteum, therefore, is the reliable factor in 
regeneration when an entire bone, with it.® closed medullary cavitv, is tran'-planted. — 
A. T. Kirk, M.D., San Francisco, California. 


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CUI?1{ENT LITERATUllK 


Internal Fixation of Fractures op the Neck of the Femur. Melvin S. Henderson. 

Archives of Surgery, XXXV, 419, Sept. 1937. 

Aftei r bi ief .survey of the anatoni 3 '’, with particular attention to the vascular supplv 
of the upper end of the femur, the author cliscus.ses the operative treatment for fractures 
of the neck of the femur incidental to internal fixation. He reports sLxteen cases and 
describes the u.se of the “lag” screw which is now being used in The Maj'o Clinic. It is 
his feeling that the internal fixation of fractures of the neck of the femur gives better 
results than the conservative treatment, but that its use must be restricted to patients 
who can withstand operative shock. — /. II ilhaiii Nachlas, M.D., Ballimore, Maryland. 


Dislocation and Fracture-Dislocation of Lower Cervical Vertebrae. Janies 

Pierce Cole. Archives of Surgery, XXXV, 528, Sept. 1937. 

Recognizing the manj' difficulties that follow the treatment of dislocations and 
fractures of the lower cervical vertebrae, the author pi-csents a historical surve}’’ of this 
subject and then makes a study of the eighteen patients with this condition seen in the 
New York Oi’thopaedic Dispensarv and Hospital between 1923 and 1933. His interest 
is not in the acute type of injuiy, but in the sequelae resulting from this. It is his feeling 
that the sjunptoms persist frequentlj-, even when there has been a closed reduction. 
The s^miptoms may be I'eferable to the bonj'’ structure, to the spinal cord, and to the nerve 
roots. If the spinal cord is involved, a laminectomj'- in conjunction with fusion is rec- 
ommended; otherwise, fusion of the vertebrae adjacent to the point of injury is found 
desirable. — I. IVilliam N'achlas, M.D., Baltimore, Maryland. 


Experimental Giant Cell Tumor and Cartilaginous Exostosis of Bone. J. Dewey 

Bisgard. Archives of Surgery, XXXV, 854, Nov. 1937. 

In the course of experiments on the bones of rabbits, injuries to the epiphyses were 
accidentally obtained. The repair that took place at these points led to the formation of 
tumors which had the characteristics of cartilaginous exostoses and, in two instances, of 
giant-cell tumors. Since the production of these new growths is based upon epiphj'seal 
separation, a condition frequentlj' seen clinicalty, a careful study of the tumors is made 
and some deductions are offered in which the experimental masses are compared with 
the changes which take place in man. — /. William Nachlas, M.D., Baltimore, Maryland. 


Sui cosiddetti “tumori giganto-cellulari” delle ossa (The So-Called “Giant- 
Cell Tumors” of Bone). Filippo Vecchione. Archivio di Orlopedia, LIT 547, 
1936. 

In this monographic presentation of the subject, a very good review of the literatuic 
is given, but no original thought is expressed. Veccliione considers the giant-cell tunioi 
of bone as a well-defined nosological entity whose pathogenesis is unknown. He does not 
believe that bone cysts represent healed giant-cell tumors. It is still questional) e 
whether or not these two forms are in genetic relationship. As far as treatment is con 
cerned, both x-ray and surgical treatment are indicated. The latter ranges from simp e 
curettement with or without caustic fluids to resection, osteoplasty, and amputation- 
Twelve personal cases are reported. — B/mst Freund, M.D., Los Angeles, California. 


Sul trattamento glicocollico della distrofia muscolarb progressiva (Gm 
COCOLL Treatment of Progressito Muscular Dystrophy). Antonio o i. 
Archivio di Ortopedia, LII, 667, 1936. . 

Poli has treated five cases of progressive muscular d 3 "sti-oph 3 " (Duchenne type; " > 
glycocoll for from three to four months. Only one case showed temporary ' 

In view of his clinical experience and of the studies of the creatine metabolism o i 

THE journal of BONE AND JOINT SURGED 



CURRENT LITERATURE 


247 


patients, the author concludes that there is no practical value in glycocoll treatment and 
apparentl 5 ’^ no connection between glycocoll and creatine metabolism . — Ernst Freund, 
M.D., Los Angeles, California. 


Atjtoplastiche ossee nelle pseudartrosi del collo del femore (Autoplasty in 
P sEUDARTHROSis OF THE Neck OF THE Femur). Carlo Re. Archivio di Ortopedia, 
LII, 689, 1936. 

The author thinks that in the treatment of pseudarthrosis of the neck of the femur 
one should be very careful in selecting an operative method. In some cases a shelf op- 
eration is the method of choice; in others, the transcervical bone graft and subtrochan- 
teric osteotomy are indicated. He has tried these different methods in various cases 
and has obtained good results . — Ernst Freund, M.D., Los Angeles, California. 


Infantile Kyphosis. B. Frejka. Bralislavsk6 Lekarski Listy, XVII, 375, Aug. 1937. 

One of the causes of round shoulders and defective posture is constant nasal obstruc- 
tion due to adenoids. The obstruction leads to buccal breathing which is superficial. 
The thorax becomes more or less fixed in e.xpiration and a thoracic kyphos results with 
the apex over the sixth, seventh, and eighth vertebrae. This deformity produces subse- 
quentlj' a forward and downward displacement of the head, a depression in the antero- 
superior joint of the thorax, and an increase of the lumbar lordosis. Prof. Frejka found 
this deformity in 80 per cent, of the children with adenoids. In 90 per cent, of the chil- 
dren affected with kyphosis, a nasal examination showed the presence of nasal obstruc- 
tion, due either to adenoids or to hj'pertrophy of the mucosa. It ensues that for 
prophylactic reasons it is important to remove the adenoids in the preschool age and to 
reestablish the nasal breathing . — Emanuel Kaplan, M.D., New York, N'. Y. 


The Movements of the Shoulder-Joint: A Plea for the Use of the “Plane of the 

Scapula” as the Plane of Reference for Movements Occurring at the 

Humero-Scapular Joint. T. B. Johnston. The British J ournal of Surgery, XXV. 

252, Oct. 1937. 

The purpose of this article is to explain certain observations made by Martin and 
Codman in regard to rotation of the humerus during elevation of the humerus in any 
plane. It is believed that there is less confusion in referring tlie movements of the 
humerus in flexion and extension, abduction, and adduction to tlie plane of the scapula. 
This is regarded as a plane drawn at right angles to the glenoid cavitj' through its greatest 
vertical diameter. 

“ When the arm is raised to the vertical — no matter what plane or planes it may move 
through in the process — at the end of the movement the humerus must lie in the plane of 
the scapula.” Full limit of elevation cannot be obtained until the movements of the 
humerus and scapula bring tlie two bones into the same plane. The writer does not ac- 
cept Codman’s paradox that the completely elevated arm is in either e.xtreme external 
rotation or in extreme internal rotation. He offers a group of diagrams to prove that, 
when the arm is raised to the vertical above the head, the humerus is rotated neither to 
the medial side nor to the lateral side. 


L.\MnniNUDi’s Oper.vtion for Drop-Foot. F. P. Fitzgerald and 11. J. Seddon. The 

British Journal of Surgery, XXV, 283, Oct. 1937. 

Twenty-four cases in which the Lambrinudi operation has been used are cited. The 
operation may bo used for drop-foot or flail-foot. There have been five failures in the 
series duo to lateral instability at the ankle. 

Previous to the openation, the procedure is planned from tracings of lateral roent- 
genognims with the idea that in certain cases the patient will wear a tajicring cork to 


VOL. X.N. NO. 1, JANUARY ICJS 



248 


CURRENT LITERATURE 


build up the back of the foot. Segments of tlie astragalus, os calcis, cuboid, and sca- 
phoid are removed and the calcaneocuboid joint is cleaned out. The cartilage on the 
posterior surface of tlic scaphoid left after removal of a notch is not removed. The cu- 
boid is brought up to the anterior surface of tlie astragalus and arthrodesed. Likewise 
the scaphoid is brought upward and forward wliich brings the foi-ward part of the foot 
partial^ or completely up in line. The foot is fixed in a short leg plaster. 


WiRBBLLUXATiON tDislocatioii of the Vertebrae). Otto Wenzl. Bruns’ Beiircige zur 

klinischen Chirurgic, CLXVI, 53, 1937. 

In all cases of dislocation and fi’acture-dislocation of the vertebrae immediate 
reposition should be attempted. Tlie author believes that operative treatment gives the 
best results. He feels that conservative treatment is advisable only in cases of disloca- 
tion of the atlas with subsequent operative fixation of the atlas. If the first two cervical 
vertebrae are wired, healing of the odontoid process can take place. In all other cases 
immediate operation should bo performed, because the marked compi'ession leads to ir- 
reparable damages. If the anterior compression is not removed, laminectomy is of no 
value and the extension treatment is ineffective for the thoracic and lumbar portions. 
The spinous process and the arch below the dislocation are removed. The luxated 
vertebra is replaced in its normal position lyv the use of hone hooks. The prognosis de- 
pends upon the amount of damage and the duration of the compression . — Ernst Bcthyiann, 
M.D., New York, N. Y. 


Die Eiuphysenlosung im Schbnkelhaes bei Jugenulichen (Separation of the Epiph- 
ysis of the Neck of the Femur in the Young). C. Giitig und A. Herzog. Brims’ 
Beiirdge zur klinischen Chirurgic, CLXVI, 85, 1937. 

In their cases the authors always observed sj'mptoms of endocrine disturbances, 
especially in patients between the ages of ten and seventeen years. There was usually no 
history of trauma, the lesion being the result of an illness. In one case epiphysiolj'sis de- 
veloped during absolute rest. The earl^’’ symptoms, as shoum by the roentgenogram, 
are: enlargement of the epiphyseal space, rarefaction, zones of calcification in the neck 
and head, coxa vara, and loss of the head. In the differential diagnosis the following 
conditions should be considered; tuberculosis, Perthes’ disease, and aseptic necrosis of 
the femoral head. Ti'eatment consists of organotherap}' with extension and absence of 
weight-bearing . — Ernst Bettmann, M.D., New York, N. Y. 


Fractures of the Forearm. George W. Armstrong. The Canadian Medical Associa- 
tion Journal, XXXVII, 358, Oct. 1937. 

This is a general article dealing with fractures of the forearm. The author gives an 
outline of the treatment which is generally recognized as proper. He emphasizes t ie 
importance of correct reduction, and believes that non-union, when it occurs in cases m 
which the fractures have been properly reduced, is due to the short period of fixation an 
to too earl}’’ movement. — D. E. Robertson, M.D., Toronto, Canada. 


Anterior Poliomyelitis in Ontario. J. T. Phair. The Canadian Medical Associa 
lion Journal. XXXVII, 386, Oct. 1937. . . 

The predicted epidemic of poliomyelitis, in keeping with its cj'clic character o ' is> 
tation, occurred in Ontario in 1937, There were thirteen cases before June 30. wring 
the first two weeks of Julj", ten cases were reported; during the second two weeks, t\\ en } 
eight cases. There was an abrupt rise during August, — fifty-seven cases in the firs v ec , 
seventy-three in the second, 230 in the third, 336 in the fourth, and 435 to Septem cr • 
From Julj^ 1 to September 4 there were 1,169 cases reported. (The epidemic con inu 
to about the first of October.) 

the journal of bone and joint surger 



CURRENT LITERATURE 


249 


The incidence is more than ten times as great as for comparative periods in normal 
epidemic years. In comparison with 1929, when the disease was prevalent in Ontario, 
there were seven times as many cases up to the end of August. In comparison with 
1930, when the most extensive previous outbreak occurred, there were three times as 
many cases for the corresponding period. 

The geographical distribution for the month of August showed 54 per cent, of cases 
in Toronto and suburban areas. 

Thirty per cent, of the cases diagnosed showed muscle weakness or paralysis. 

“The Provincial Department of Health has attempted to assist the health authori- 
ties and phj'sicians in the affected areas by placing at their disposal the services of spe- 
cial!}" trained physicians to aid in the diagnosis of doubtful cases. These diagnosticians 
have been located at convenient centres in those sections in which the disease is most 
prevalent. Sixteen physicians are engaged in this service. The Department has, 
further, placed respirators at strategic centres, and is prepared to ensure rapid transporta- 
tion to those centres of all cases showing evidence of involvement of respiratory muscles. 
Every effort is being made to ensure the maximum of early orthopaedic treatment in all 
cases with paralysis.” — D. E. Robertson, M.D., Toronto, Canada. 


WlRBELBRiiCHE UND WlRBELVERRENKUNGEN,' EnTSTEHUNG UND BeHANDLUNG DER 
Querfortsatzbruche. Angeborene Lendenrippen. [Fractures and Disloca- 
tions of the Vertebrae; Etiology and Treatment of Fractures of the Transverse Proc- 
esses. Congenital Lumbar Ribs.] L. Bohler. Der Chirurg, VIII, 121, 1936. 

The author emphasizes the importance of the differential diagnosis in cases of con- 
genital lumbar ribs. The presence of gas bubbles proximal to this process should be taken 
into account. The margin of the psoas muscle, kidney stones, and epiphyseal spaces 
may obscure the diagnosis. The transverse processes play no part in the supporting 
function of the spine, and, for that reason, in the treatment the application of support by 
braces is not advisable. An operation is preferable when there is evidence of rupture of 
the soft tissues. — Ernst Bettmann, M.D., New York, N. Y. 


Old Dislocation of the Hip Joint with Fracture of the Acetabulum. A. Gruca. 

Chirurgja Narzadow Ruchn i Ortopedja Polska, X, 79, 1937. 

The author reviews Campbell’s work on posterior dislocation of the hip with fracture 
of the acetabulum and describes a complicated case of dislocation of the hip joint accom- 
panied by a multiple fracture of the acetabulum. Examination of the patient two months 
after the accident showed a consolidated malunion of the acetabulum, paralysis of the 
sciatic nerve, posterior dislocation of the femoral head, and considerable impairment of 
function. The patient was operated upon. The acetabulum was reestablished; the 
posterior fragment of the fractured acetabulum was fixed in its proper place by a nail; 
the head was placed back into the acetabulum; and the neoplastic periarticular bone ti.s- 
sue was removed. Reexamination of the patient one year after operation showed ab- 
sence of pain, limp, and shortening, almost normal flexion, extension and abduction of the 
thigh, and some restriction of adduction of the thigh and of dorsiflcxion of the foot. — 
Emanitcl Kaplan, M.D., New York, N. F. 


La DE.SARTicuLACidN Inter-Ilio-Sacro-Pubica. Dario Fernandez Fierro. Cinigia 
y Cirujanos, V, 169, 1937. 

The author reports an interiliosaeropubic disartieulation whieh lie performed suc- 
cc.ssfully on June 11, 1936, on a woman with a metastafie tumor of the ilium. From the 
location and character of the tumor, he believed that only this type of operation or that 
of Billroth-,Iaboul.ay eould save the patient’s life. After a thorough review of the litera- 
ture on this .subjeet, consultation with his staff, and study of cadavera, the following 
technique was perfected. 


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CURRENT LITERATURE 


An incision, two centimeters above the symphysis pubis and running parallel to 
Poupart’s line and the crest of the ilium up to and level with the spine of the ilium, is 
made. From the anterior superior spine of the ilium another incision is made in the di- 
rection of the greater trochanter, through tiie gluteal furrow and the genitocrural furrow 
up to the point where the incision began. 

The soft parts are then divided their full length following the line of the first incision, 
including the cellular tissue, the aponeurosis, the obliquus externus abdominis, the ob- 
liquus internus abdominis, and the transversus abdominis up to the preperitoneal cellular 
tissue. Great care should be taken to protect and isolate the .spermatic cord in the male 
and the round ligament in the female. The psoas muscle is isolated and its superior por- 
tion is sectioned, and the femorocutaneous and genitocrural nerves are cut. The crural 
and the obturator nerves are next sectioned, a novocain solution having been previousl}' 
injected. The common iliac artery and vein are then ligated temporarily or permanently 
if the ligation of the external iliac artery and the branches of the internal iliac artery can 
be done as thej’’ are being sectioned off. The external iliac artery is ligated at its extreme 
distal end, as was done with the obturatoj', to prevent the seeping of blood from the ex- 
tremity as it is handled. The dissection of the peritoneum is continued anterior and pos- 
terior to the pelvic cavity, so that the region of the s 3 'mphysis pubis ma}’’ be completely 
uncovered and the bladder, the intestinal mass, and the ureter maj' be pushed back. The 
gluteus maximus is next divided, followed bj' division of the gluteus medius, gluteus 
minimus, and the piriformis to a point on a level with the greater trochanter; this is ac- 
complished bj' rounding with the scalpel the superior, anterior, and posterior borders of 
the trochanter. 

An incision, the full length of the cre.st of the ilium and a little below it, is made, so 
that the gluteal muscles may be detached along the full length of the external aspect of 
the ilium, the border of the sacrum, the cocej'x, and the external surface of the greater 
sacrosciatic ligament. During this step, the gluteal and ischiatic vessels are ligated and, 
at this time, the decision as to whether or not to untie the ligatures of the common iliac 
artery and vein may be made. The dissection of the fold is continued and, at the level 
of the greater sciatic notch, the gluteal and greater sciatic vessels are divided. The 
sciatic nerve is sectioned off, a solution of novocain having been previouslj^ injected. 

The dissected area is explored veiy carefully to make sure that the sjmiplysis pubis 
is completeb^ free. If the patient is a male, care should be taken to push back the 
spermatic cord, the penis, and the testicles; if a female, the same procedure should be 
followed with the round ligament. If this ligament has been cut, it should be fixed to 
the aponeurosis of the rectus, as is done when dealing with an inguinal hernia. The 
symphysis pubis is divided; the iliacus is separated; and the dissection is continued, keep- 
ing as close as possible to the descending ramus of the pubis. Hemorrhage can be con- 
trolled by compression. Finall}^ a point is reached at which the iliac bones cannot be 
separated further, and the dissection is carried through the posterior part of the pelvis 
to the sacro-iliac symehondrosis, and the iliacus is divided. After ligation of a few of t le 
iliolumbar vessels, the disarticulation is begun, starting posteriorl}^ By so doing, le 
articular interline can be located, which permits a little more separation of the ilia,c bones. 
The final step consists of the division of the remaining soft tissues and the sacro-iliac an 
sacrosciatic ligaments. After this has been done, the extremity is detached, leaving a 
thick and well-nourished fold. The muscles of the fleshy^ fold are nourished by the nius^ 
cles of the abdominal wall and the skin. A drain is left at the center of the fold. c'" 
Finck, M.D., Torreon, Coah., Mexico. 


Die Periarthritis humeroscapularis (Humeroscapular Periarthritis). Hans c lae . 

Ergehnisse der Chirurgie imd Orlhopiidie, JOLYK, 2l\, , 

This complicated clinical picture, first described in 1872, is thoroughlj' ana j zc ai^^ 
revised by the author. The affection presents various pathological changes, 
following conditions are described: (1) post-traumatic stiffness, (2) lesions of t ic sup 

the journal of bone and joint surglrx 



CURRENT LITERATURE 


251 


spinatus tendon (rupture, etc.), (3) bursitis, (4) apophysitis, and (5) arthrosis of the inter- 
tubercular sulcus and acromiocla^-icular artliritis. The author emphasizes the diag- 
nostic importance of local tenderness above the following points: tuberculum majus, 
tuberculum minus, sulcus bicipitalis, processus coracoideus scapulae, and the acromio- 
cla\'icu]ar joint. Traimra to the supraspinatus tendon causes tenderness two inches out- 
side tlie acromion in the center of the deltoid muscle. The Bettmann shoulder-ridge 
symptom (shortened neck and shoulder line, elevated shoulder) and atrophy of the 
supraspinatus and the infraspinatus muscles are often present. The painful locking in 
abduction between 60 and 100 degrees and painful rotation are pathognomonic. The 
rupture of the supraspinatus tendon is often due to degenerative changes associated with 
calcareous pseudobursitis. The e.vistence of calcification is usually the result of an acci- 
dent. The author often advises the application of a plaster-of-Paris cast. Eadiation 
and novocain anaesthesia are also recommended. — Er7is{ Bettitiann, M.D., Xew York. 
X. Y. 


Die entzCntiijchex Erkhankuxgek der Kxieschzibe (Inflammatorj" Diseases of the 
Patella). C. Blumensaat. Ergebnisse der Chiriirgic iind Orlhopddie, XXIX, 310, 
1936. 

The following inflammatory diseases of the patella have been observed by the author: 
osteomyelitis (which is usually secondaiy), bursitis, tuberculosis, and lues. In osteo- 
myehtis the change is due to the slower circulation and larger blood supply in the apo- 
physis of the patella. The treatment consists of curettage, if total resection is not neces- 
saiy. The tuberculous changes are accompanied with effusion, as is also bursitis, which, 
in contrast to osteomyelitis, is confined to the patella only. Early operation is recom- 
mended. The verj- rare lues of the patella is characterized by severe pain at night and 
marked periostitis. Tabetic changes are rather frequent and show marked atrophy. — 
Ernst Bettmann, M.D., Xetc York, X. P. 


Die Tumoben’ der Iastescheibe (Tumors of the Patella). C. Blumensaat. Ergeb- 
nisse der Cliirurgie und Orthopadie, XXIX, 347, 1936. 

The most frequent tumors are osteomata and chondromata, with enlargement and 
shifting of the patella. Resection is recommended. Sarcomata, as periosteal and cen- 
tral tumors, grow rather slowly and in every case biopsy should be done. Myelomatous 
and carcinomatous metastases are rare and can be mistaken for osteitis fibrosa with giant 
cells. — Ernst Bettmann, M.D., Xew York, X. 1'. 


Entj Results ix FiLicruRES of the Sh.^ft of the Femur, Eldridge L. Eli.ason and 

John Paul North. Journal of the American Medical Assoaation, CIX, S4S, Sept. 11, 

1937. 

The writers report seventy-four fractures of the femoral shaft treated by variou.s 
methods. They advocate conservative treatment based upon the fundamental prin- 
ciples of fracture treatment. 

In discussing different methods of traction, they point out that the one best suited to 
the individual case should be selected and that it must be continued uninterruptedly 
until firm union occurs. In their opinion, skeletal traction is nc.\t to openitive reduction 
in efiiciency. Russell traction is only fairly satisfaeton’ and should be discarded for an- 
other method if good alignment is not obtained in a few d.ays. In muscular patients with 
definite shortening, skin traction should not bo employed. In small rhildrcn, h.owcver, 
vertical suspension of botli legs with tlie hips fle.xed to 90 degrees is considered the nio-t 
effective. 

Plastcr-spica fixation m.ay be used with caution in c.a.-es without dL-placenient and 
in those in which callus holds the fragments together. Frc-sh fractures are apt to «Iip in 


VOL. XX, XO. 1. J.XXU.VRY IMv 






CURRENT LITERATURE 


253 


plastic operation restores the normal angle of the radial articular surface, corrects the 
radial shortening, and produces a normal contour of the ulna. This is accomplished by a 
transverse osteotomy of the radius about one inch above the wrist. The medial portion 
of the distal one inch of the ulna is removed and is used as a bone wedge between the 
fragments of the radius. This is placed in such a manner that its widest portion lies 
dorsally and laterallj' thereb 3 ' correcting both the radial deviation of the hand and the 
radial articular angle. The discus articularis is anchored subperiostealij' or to the bone 
bj' means of a drill hole through the ulna. 

Results in nineteen cases have been uniformlj' good. Of these, eleven known end 
results are excellent. In one other case the result was not satisfactorj"^, as excess mobilitj' 
of the distal ulna was present. This was due to a ruptured interarticular fibrocartilage. 
.'^.dvantages claimed bj' the author are the restoration of practically normal function and 
the correction of an unsightlj’ deformitj'. — TT^. B. Carrcll, M.D., Dallas, Texas. 


The Care of the Feet iu Chrontc Arthritis. John G. Kuhns. Journal of the Amer- 
ican Medical Association, CIX, 1108, Oct. 2, 1937. 

According to Kuhns, the joints most frequentlj’’ affected b 3 ^ chronic arthritis are 
those of the hands and the feet, but more attention is given to rehabilitation of the hands. 
Much, if not all, of the pain and defonnit 3 ' can be avoided b 3 ' early and adequate treat- 
ment. He outlines the general measures used in treating over 1200 patients with this 
condition. 

The only certain method of preventing late disability is by the avoidance of weight- 
bearing until the pain and swelling have subsided. Heat and immobilization may also 
be necessar 3 ' at first, followed by graduated exercises. Finall 3 % proper shoes with sup- 
ports and correct posture are essential. 

The most common condition of an untreated case is a foot rigid in valgus. Because 
weight-bearing is fault 3 ’, strains at the knee and hip are produced. There is atroph 3 ' of 
the intrinsic musculature and a subsequent flattening of the anterior arch. This is fol- 
lowed b 3 ’’ pressure on the metatarsal heads, with resultant pain. This deformit 3 ’ further 
aggravates the inflammatory condition of the joints. Forceful correction under anaes- 
thesia ma 3 " be necessaiy in the late stages. Among late complications of chronic arth- 
ritis, the author mentions hallux valgus, contracted-toe deformit 3 ', ank 3 'losis of the small 
joints, and spur formation on the tarsal bones. The latter is due in most instances to a 
chronic strain rather than to infection. Another disabilit 3 ' of the arthritic foot is epi- 
dermom 3 'cosis. The impaired circulation of the foot causes this extremit 3 ' to become 
frequentK affected. 

Both local and S 3 ’stemic treatments are indicated in caring for the feet of arthritic 
patients. Earb' and adequate measures will prevent painful complications and deformi- 
ties. Good bod 3 ' alignment is also essential to ensure permanent cures. — H. J/. Childress, 
M.D., Dallas, Texas. 


Foot Disorders ix Gexeral Practice. Dudle 3 ' J. Morton. Journal of the American 

Medical Association, CIX, 1112, Oct. 2, 1937. 

The writer is critical of the view that most foot disorders arc due to fault 3 ' shoes or to 
weakened musculature of the feet. In di.^cussing the anatonn- and the functioning of the 
foot, he .states that the first metatarsal is of the greatest functional importance. In 
standing, it supports twice the load held up In' the other metatarsals, and in motion it 
alone, witli its as.sociated muscles, sustains half of the greath' increased strc.~s placed 
upon the foot. When there is a functional deficienci-, as in a pronated unb.alanced po— 
ture, the strcs.«es are concentrated on the .second metatarsal which soon shows In'pcr- 
tropln-. This pronation is due to a failure of the first metatar-al to carri- it.s burden: 
there is a shift of weight medialK'; and a progrcs.-;ivc condition is started which emb in a 
rigid flat foot. 


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252 


CURllENT LITERATURE 


the plaster fixation, and this should be watched for with frequent x-rays. Also, per- 
manent damage may be done to the knee joint by long immobilization. 

Surgery should be used as tlie last resort and in the authors’ series the results did not 
justif}' the procedure. 

Tire authors conclude that cmpliasis should be placed on restitution of function, and 
that perfect anatomical r’eduction is not essential. Skin ti’action on the thigh is least 
effective, it being satisfactoiy in only 1 1 per cent, of the cases in which it was used. 
Skeletal traction was adequate in 02 per cent. Perfect results were obtained in over 
90 per cent, of the childi'cn in this scries, whereas only 64 per cent, of the adults escaped 
without pei-manent disability.— IP. B. Carrell, M.D., Dallas, Texas. 


Hypertrophy of the Ligamenta Fl.ava as a Cause of Low Back Pain. R. Glen 
Spurling, Frank H. Mayfield, and James B. Rogers. Journal of the American Medi- 
cal Association, CIX, 928, Sept. 18, 1937. 

The authors believe that low-back pain, associated with objective sensoi'y and motor 
neurological changes, is caused by an intraspinal lesion. The}’^ point out that the hyper- 
plasia of the ligamenta flava as such a lesion is not general^ recognized. The report is 
based on seven operated cases with this pathological finding. In si.v of them the lamina 
of the fourth lumbar vcrtebi'a was increased in thickness which might have been a part 
of the causative factor. 

In each case the patient gave a history of trauma, radiating pain down one or both 
legs, and discomfort not relieved bj-- recumbency. In four of the seven patients there was 
objective motor loss, two of them having definite atroph 3 ^ For diagnosis an adequate 
neurological e,\'amination is essential to differentiate between an extraspinal and an intra- 
spinal lesion. If the total protein of the spinal fluid is elevated, a subarachnoid injection 
of two cubic centimeters of iodized oil is indicated. In the six cases in which this was 
done, a characteristic filling defect was shown opposite the fourth lumbar interspace, 
In order to obtain sufficient exposure, the laminae above and below the lesion were re- 
moved. The ligamenta flava showed marked lu'pertrophy with some areas of calcifica- 
tion. Microscopic examination shorved a marked amount of cicatricial tissue. No signs 
of old or recent infection were present. To find the normal thickness of the lamina of 
the fourth lumbar vertebra, ninety-three spines were measured, and the lamina of the 
fourth was found to be about the same size as that of the third and fifth. The ligamenta 
flava in the lumbar areas of forty cadavera examined were found not to be hj^pertrophied 
at the fourth lumbar inteiwal. 

With the exception of one fatality from streptococcic meningitis, the results were ex- 
cellent. Sensory and motor disturbances rapidly returned to normal. Three impotent 
patients recovered in from one to five days. Thi’ee returned to hard labor in six weeks. 
The writers conclude that this ligamentous lij'^pertrophy was due to trauma. In the 
process of healing, or as a result of continuous trauma, an excess of scar tissue formed. 

H. M. Childress, M.D., Dallas, Te.ms. 


Maluniteb Colles’ Fractures. Willis C. Campbell. J ournal of the American Met i 
cal Association, CIX, 1105, Oct. 2, 1937. . . 

Presented in this paper is a surgical procedure for the restoration of anatomica 
alignment and the function of a wrist disabled bj' an old Colies’ fracture unsuccess u } 
treated. In the author’s opinion, malunion is due to one or more of the folIo\Mng. 
failure to obtain propei’ reduction; recwrence of deformity after apparent leduction, c.' 
cessive comminution with radial shortening; complete rupture of the radio-ulnar ligamcn 
with undue mobility of the distal ulna; too earty plysiothej'apy before firm union 

velops. ... „(.] 

In describing this deformity, the author stresses in particular the radial devia ion 
the widening of the wrist. Simple osteotomy of the radius may aid m promoting im ^ 
tion, but it does not correct the abnormal contour either of the radius or of the ulna. 

THE JOURNAL OF BONE AND JOINT SURGER'' 



CUHBENT LITERATURE 


255 


but, in general, local overgrowth is uncommon. Disturbed growth hormones may cause 
local hypertrophy, but the reasons for this are not known. 

The writer points out that little is known of the causes for this upset in sj^mmetrical 
growth and that such an undeveloped field should arouse the interest of research workers. — 
TT^, B. Carrell, M.D., Dallas, Texas. 


The Practical Application of Physiological Principles in Treatment of Frac- 
tures. Willis C. Campbell. Khirurgiya, I, 72, 1937. 

The biology of the healing of fractures is reviewed, and basic principles of treatment 
are outlined. The routine treatment is summarized as follows: 

1. Good reduction from inspection of the e.xternal contour checked by the roentgeno- 
gram. 

2. Roentgenographic confirmation of reduction without removal of splints at the 
end of one week. 

3. Removal of immobilization while callus is malleable, roentgenographic check-up, 
and correction of any angulation. 

4. In certain fractures, continued protection for an indefinite period until absolute 
consolidation can be shown by roentgenographic and clinical e.\'aminations . — Emanuel 
Kaplan, M.D., New York, N. V. 


Pathogenesis and Therapy of Konig’s Osteochondritis in Connection with Two 
Cases. M. Z. Rotenfeld. Khirurgiya, I, 93, 1937. 

A description of a rare localization of osteochondritis is given. In two cases the proc- 
ess involved the lateral condyle of the femur, and in one case, the head and neck of the 
radius. The pathological diagnosis is differentiated from other processes in this area. 
The treatment consisted of iron and potassium-iodide therapj', with satisfactory results 
as far as function of the joints was concerned . — Emanuel Kaplan, M.D., New York, N. F. 


Reduction of Posterior Dislocations of the Forearm. B. A. Peskin. Khirurgiya, 

I, 97, 1937. 

The author reviews the known methods of reduction and describes his own. The 
patient is placed on a chair sidewise, with a folded towel under the arm pit of the injured 
limb to protect it from the back of the chair. The surgeon places his knee on tlic volar 
surface of the forearm near the elbow joint and produces downward pressure while the 
distal end of the forearm is first being supported and tlien slowly fle.ved by his hand. 
This method produces less trauma to the articular surfaces and does not require the ap- 
plication of great force . — Emanuel Kaplan, M.D., New York, N. Y. 


The Technique of Reduction of Shouldep.-Joi.nt Dislocatio.ns. a. A. Kudryavtsev. 

Khirurgiya, II, 1G4, 1937. 

A new method of reduction is described. The patient is placed liorizontally, lying 
on the undislocated side with tiie arm stretched out along the liody and the hand com- 
pletely pronated to prevent iiim from lifting his body up while the actual reduction take-s 
place. A cuff is attached to the wrist of the di.slocated arm and by means of a cord is 
pulled up and fi.vcd above in such a manner that the trunk of the patient is lifted .slightly 
from the horizontal plane and the dislocated arm, abducted by the pull, forms an angle of 
about 1 10 degrees with the chest of the patient. To overcome the resistance of the mus- 
cles, the usual amount of morjihine .sulphate is injected before the reduction. It is 
claimed that reduction takes place in from one to five minutes, and is successfn! in c.ases 
where other methods fail . — Emanuel Kaplan, M.D., A'rir York, .V. Y. 


VOL, XN. NO. 1. JANL'AUY I03S 



254 


CUllKENT LITERATURE 


In In’s estimation, most foot disorders are primarily due to a functional deficiency of 
the first metatarsal segment. Secondary changes are traumatic artliritis and strain 
upon ligaments of the long arch. There may be accompanying vasomotor changes in 
the foot, ai-eas of numbne.ss, and even radiating pain up the legs. Treatment consists of 
local applications to superficial irritation, rest and physiotlierapy for the deep trauma and 
the inflammatoiy changes, and a correction of the disordered mechanics bj^ changing tlie 
patient’s shoes as indicated.— 77. il7. Childress, Dallas, Texas. 


Pain Low in the Back and “Sciatica” Dub to Lesions of the Interveiitebr.\l 
Discs. J. S. Barr, A. O. Hampton, and W. J. Mi.xter. Journal of the Americnn 
i\Iedical Association, CIX, 1205, Oct. 16, 1937. 

Ruptures of the intervertebral discs are not rare according to the authors wiio report 
fifty-eight operated cases. Sucli pathology usuall}’' is found in healthy vigorous men from 
twenty to fiftj'^ years of age. A history of trauma was found in 80 per cent, of the 
authors’ cases. Pressure upon one or more roots of tlie cauda equina produces signs and 
symptoms similar to those found in sacrolumbar and sacro-iliac strains with “sciatica”. 
The most characteristic sign is a limitation of lumbar motion by muscle spasm. A list, 
to or from the affected side, is frequent. Neurological findings maj’^ be normal in about 
50 per cent, of the patients. The most common positive neural sign is an absent or di- 
minished knee jerk. 

Roentgenographic examination revealed significant variations in but one-half of the 
cases. Schmoi'l’s nodule urns observed occasional!}’', but had no definite relationship to 
the condition discussed. Low lumbar puncture should be done in all suspected cases. 
Fifty-two patients of this series had a total protein of over forty milligrams per 100 cubic 
centimeters. If the spinal-fluid total protein is high, the diagnostic use of iodized oil is 
indicated. The lesions may be accurately localized with the oil injection. It must be 
controlled along the anterior and lateral surfaces of the canal, as this is where the path- 
ology is found. No damage was produced by the use of this oil in any case. Serial x- 
rays of the oil in the canal are essential. The filling defects must be correctl}’’ interpreted. 
If no such defect is shown in the anteroposterior roentgenogram, the test is considered 
negative for evidence of a ruptured disc. Rupture of the fifth lumbar disc is difficult to 
demonstrate, and it is better to reexamine the patient two weeks after the injection. At 
this time the nerve sheaths and the lateral portion of the canal will be well out- 
lined. 

In thirty-two of the operated cases studied complete relief was obtained; ni 
twelve improvement was noted; only two were classed as failures. The writers believe 
that no accurate clinical diagnosis of low-back pain with “sciatica” is possible without 
roentgenographic examination. Iodized oil should be used when conservative treatment 
is unsuccessful. The operative mortality is low, the percentage of cures high. 77. 
Childress, M.D., Dallas, Texas. 


Local Overgrowth. Fremont A. Chandlei-. Journal of the A merican Medical Associa- 
tion, CIX, 1411, Oct. 30, 1937. 

The author believes that defective growth may be due to deficiency of germ plasm, 
circulatory failures occurring in early embryonic life, or epiphyseal disturbances. One or 
more of these factors may produce an overgrowth or an arrest of growth, locallj’ or gen 
erally. Unilateral arrest of growth is treated successfully by shortening the \\el ex 
tremity. Bilateral arrest of growth, however, brings up the question of treatment w i ' 
endocrine products and vitamin therapy. 

Overgrowth is due to an epiphyseal stimulation which, in turn, is caused by an in 
crease in tbe epiphyseal blood supply. Trauma, infection, foreign materials, ant some 
chemicals at or near the epiphysis are the usual inciting factors. Arteriovenous 
and lymphatic obstruction by parasites may cause overgrowth, provided the con mo 
occurs during the period of growth. Endocrine imbalances may be somewhat se ec I'Ci 

the journal of done and joint SURGF.nV 



CURRENT LITERATURE 


257 


lesions, carditis, nodule formation, and multiple arthritis have been experimentally pro- 
duced in animals. 

Poynton and Paine originally explained rheumatism as a generalized secondary in- 
fection of the joints, heart valves, fascia, etc., coming from an original focus, the tonsils, 
just as a general infection producing multiple abscesses may originate from some primarj' 
purulent focus. However, just how this infection travels from the primary focus to the 
secondarj' locations is not explained nor understood. 

•The objections to the infection theories are based upon the fact that very seldom are 
streptococci found in the secondarj'- lesions or in the blood stream, although they may be 
found in the primarj^ lesion. This fact leads manj'' workers to hold to the allergic theorj’. 
This theory pictures a local focus pouring into the bodj' streptococcal poison or antigen. 
This antigen in the circulation stimulates the reticulo-endothelial cells to produce a spe- 
cific antibod 3 '. If the production of antibodj’ is good, the antigen is neutralized in the 
circulation and no harm is done to the body cells. However, if the antibodj' response is 
poor, the antigen combines with the antibodj' in the cells and produces cell destruction. 

Studies in regard to the virus theorj' are still in the infantile stage, since highlj' spe- 
cialized investigations are required and the accuracj' of these studies depends on the skill 
of the laboratory investigators. 

Rheumatism in adult life maj' be complicated bj' glandular dj'sfunction, climatic 
conditions, habits, occupation, injuries, etc. All or nearlj' all the glands have been in- 
criminated, but the view now most supported is that two or more of them acting together 
are responsible. 

The role of metabolic disturbances in rheumatism is uncertain. A patient who over- 
eats and underexercises may develop a goutj' tendencj' and thus be below normal in his 
abilitj’ to resist infections, but, outside of this observation, little else can be definitelj- 
stated in regard to the relationship of metabolic disturbances to rheumatism. 

Injurj' and degeneration of the articular structures may play a part in old-age arth- 
ritis. In old age there is a diminished blood supplj' to the joints, with the result that the 
cartilages become thin and split and the e.xposed bone is worn down and roughened. 

Fibrositis is an aspect of rheumatic involvement. Infectious (apparently) nodules 
form in fascia and tendon sheaths. These may come on slowlj' and last a long time. 
The ordinarj' stiff neck or “crick” in the neck gives sj'mptoms similar to the rheumatic 
involvement of the same structures, j'et it surely cannot be an infection developed in 
those muscles overnight. This leads us to consider the reaction of nerve endings and 
skin circulation to the sj’stem in general. These maj' also be factors in the onset of rheu- 
matism . — Herbert E. Hipps, M.D., Marlin, Texas. 


Chronic Rheumatic Arthritis. H. Warren Crowe. The Medical Press and Circular, 
CXCIV, 426, 1937. 

Bj' the term “chronic rheumatic arthritis” the author means the residue of joint 
disease which is left after exclusion of acute joint disease, an injured joint, a specific 
arthritis, and gout. 

The author discusses the sj'mptoms, phj'sical findings, and differential characteris- 
tics of rheumatoid arthritis and osteo-arthritis. His opinion is that tlie former is infec- 
tious in origin and the latter is degenerative, although there maj' be a mixing of the two 
tj'pos chieflj' in older individuals. 

Treatment of rheumatism consists of (It prevention of deformitj', (2) correction of 
existing deformities, (3) postural training, (4) phj'.sical therapeutic methods to increase 
’ muscle tone and to reduce pain and inflammation, (ol rest, and (Ol vaccine.*. 

As a rule, drugs have been unsuccessful, although aspirin and otiier sedative.-; are 
valuable. 

Focal infection should alwaj-s lie kept in mind. 

The author goes into detail in explaining how vaccines should be given. If a patient 
has anj' kind of a reaction following an injection, the doseshouhl be decrea.scd matcriallj'. 

von. .x.x. NO. I. January ims 



256 


CURRENT LITERATURE 


Some Physiological Aspects of Natural and Artificial Sunlight. F. S. Cooksey. 

The Medical Press and Circular, CXCIV, Supplement, i, 1937. 

It is generally accepted that artificial sunlight for therapeutic purposes refers only 
to the ultra-violet ray^s, and only' these rays are considered in this article. The ray's ad- 
jacent to the visible spectrum are referred to as the long, near, or biotic rays (3900 A. to 
2900 A., A representing the Angstrom unit of wave-length) and the remainder as the 
short, far, or abiotic ray's (2900 A. to 1800 A.). The long ray's are stimulating to animal 
and vegetable protoplasm, while the short ray's are destructive. 

The abiotic rays may' be used therapeutically to sterilize the skin in acne and multi- 
ple furuncles, the surface of indolent wounds and ulcers, and the conjunctival sac as a 
preliminary' to ophthalmic operations, etc. They do not penetrate below the stratum 
corneum of the skin and will be almost completely' absorbed by' the air if the patient is 
more than two feet away' from the radiating source. The abiotic rays are not present 
in the natural sunlight at the earth’s surface, being absorbed by' the atmosphere. 

The ery'thema reaction to the biotic ray's varies with the amount and character of 
ultra-violet ray's absorbed, and is most pronounced with rays of about 2970 A. The 
first-degree ery'thema causes only a brief slight flushing of the skin and no discomfort. 
In the second degree the skin is a bright pink, there is some irritation, and fine peeling 
and pigmentation follow in a few days. In the third degree there is intense redness with 
much discomfort lasting some days and followed by' coarse peeling and deep pigmenta- 
tion which may' persist for many' months. The fourth-degree reaction is a blister, fol- 
lowed by scarring. 

The first-degree and second-degree reactions provoke a cutaneous vasodilata- 
tion which may' last forty-eight hours. They' effect an acceleration of the functions 
of the skin, and secretion of sweat and sebaceous glands and excretion of urea are 
increased. 

It may' be said that exposure to sunlight raises the subnormal but does not affect the 
normal phy'siological activity of the skin. Patients with low vitality following debili- 
tating illnesses respond well to sunlight. Much of the value of sunlight lies in the fact 
that the cutaneous stimulus is sustained, while it fades with the cessation of other treat- 
ments such as heat, cold baths, exercise, etc. Pigmentation varies with the degree of 
erythema produced. The pigment absorbs ultra-violet rays and converts the energy 
into heat. As the pigment deepens, a longer exposure becomes necessary' to produce 
the same reactions. The function of the pigment is to protect the body against e.xcessive 
exposure to sunlight; if several weeks are allowed to pass without exposure, a smaller dose 


is required although pigmentation persists. 

Activated by the ultra-violet ray's, ergosterol is converted in the skin into vitamin 
D; the antirachitic rays are sharply defined about 2980 A. Sunlight prevents and cuies 
rickets by supplying the necessary vitamin for the regulation of the calcium and phos 


phorus metabolism of bone. 

Ultra-violet I’ay's liave a stimulating action coincident with the onset of erythema 
and a late sedative action an hour or so later. Drowsiness is commonly experience 
during irradiation. If the dose has been excessive, the absorption of breakdown pioduc s, 
following wide-spread destruction of epidermal cells, gives rise to general malaise, nausea,^ 
and headache, and later to soreness of skin, mental irritation, and restlessness. Her c 


E. Hipps, M.D., Marlin, Texas. 


The “Nature” of Rheumatism. F. J. Poy'nton. The Medical Press and Circular, 

CXCIV, 416, 1937. - • tl orv 

After forty years oi intense work and study on rlieumatic disease, the infection ic 

still holds the most prominent place, although the exact nature of the infection an 
mode of action are still warmly contested. 

Investigations based upon the streptococcal-infection theory' have taugi u® 
meaning of the local focus, and, with micrococci obtained from these foci and r leuma 

THE JOURNAL OF BONE AND JOINT SORGER 



CURRENT LITERATURE 


259 


DeS RAIDEURS ARTICULAIRES APRES LES BXITEES OSTEOPLASTIQTJES DE HANCHE (ARTHRO- 
PATHIES post-op£ratoires). (Articular Stiffness after Osteoplastic Shelf Opera- 
tions on the Hip (Postoperative Arthropathies),] Tavernier et Albert Trillat. La 
Presse Midicale, XLV, 1051, 1937. 

The articular pain which is so common in hips about which osteoplastic shelves have 
been turned down constitutes a special category of postoperative arthroses. They ap- 
pear invariablj' in patients past the age of five, in whom the femoral head has been forc- 
ibly brought down to the level of the acetabulum and the shelf acts as an efficient block to 
dislocation. The condition is characterized by a true articular stiffness, which frequentl 3 ' 
does not jdeld even under anaesthesia. Pain is not present and deformities do not 
develop. 

The x-ray shows osteoporosis, without narrowing of the joint outline. For a period 
of about three j’ears the stiffness persists; then graduallj' the mobilitj' present before 
operation returns. During this time the bone undergoes a gradual osteoporosis for a 
period of about two j^ears and then graduallj' recalcifies. 

The authors attribute the condition to capsular tissues. Thej' consequently recom- 
mend that no effort be made to pull the femoral head down in those cases in which a 
shelf operation is contemplated. Thej' further caution against anj- hastj' arthroplastic 
procedures in these cases of postoperative arthroses . — Henry Milch, M.D., New York, 
N. Y. 

L’etiologib DU torticolis muscuuaire (The Etiologj’ of Muscular Torticollis). Wer- 
ner Schmid. La Presse Medicals, XLV, 1189, 1937. 

The opinion is expressed that the origin of torticollis is to be sought, not in the 
mother, but in the foetal structures. The muscular ischaemia is brought about first bj* a 
perifoetal cause, oligohj'dramnios, due to abnormality of the foetal membranes; and sec- 
ond by an endofoetal cause, a failure of normal differentiation of the mesenchj’me. A 
genealogical table is added. The author is of the opinion that “torticollis is a hereditary' 
disease, recessive in the genotype and probabty bihybrid ”. — Henry Milch, M.D., New 
York, N. Y. 


Quan'd et co-MMExt pratiquer la vaccination" p.ar le BCG (When Should Vaccination 
with BCG Be Undertaken)? Jean Paraf et Boissonet. La Presse Midicale, XLV, 
1307, 1937. 

The authors insist upon the value of vaccination against tuberculosis by means of 
Calmette's BCG. Thej' note that the vaccine has not proved of much value in those 
children who are subject to repeated massive infection from parental sources. On the 
other hand, if the children are removed from these contacts and are subject to only cas- 
ual infection, the method has proved definitely valuable. In such cases the vaccination 
need not be undertaken before the age of six . — Henry Milcii, M.D., New York, N. Y. 


Reflexion sur lb syndrojib d’embohe arterielle des mejibres (The Syndrome of 

Arterial Embolism of the E.xtremities). Marc Iselin et R. Heim de Balsac. La 

Presse Midicale, XLV, 1373, 1937. 

The authors performed arteriotomj’ for thrombosis in four patients. Three of these 
patients died and careful post-mortem e.xaniinations were possible. The authors draw 
the following conclusions: 

1. In cases which are clinically typical of emboli.^m, the punitive phenomenon is 
that of loss of arterial pulsation. Tliis segmental arterial paraly.-^is ran he e.vplained 
only on a regional nerve basis. 

2. The clot forms secondary to the cessation of arterial pul.'^ation. 

3. The arterial-trunk circulation and circulation to the e.xtremities are entirely in- 
dependent of each other. 


'■OL. XX. NO. 1, JANUARY I93S 



258 


CURRENT LITERATURE 


Rest is itself an extremely important part of the treatment of such a condition. 

Recalcification of the bone, improvement in the blood picture, and gain in weight 
and general health are important signs of recovery, and they sometimes occur before 
pain reduction. Proper attention to all those details over a long period of time is neces- 
sary before a cure can be obtained.— //crfeert E. Hippa, M.D., Marlin, Texas. 


Hallux Valgus: Study of End Results of 339 J3unionectomies. W. R. Hamsa. 

Nebraska Stale Medical Journal, XXII, 225, 1937, 

Dr. Hamsa presents a splendid and timely paper on the subject of hallux valgus. 
There is so much conflicting information on the subject in medical literature, and so many 
different methods of operative repair are described by various authors, that to the average 
practitioner the subject presents a picture of the wildest confusion. Dr. Hamsa has very 
carefully compiled a table of all the various procedures used in the treatment of this 
condition, and has made a careful study' of the etiological factors involved. 

He states that in the Orthopaedic Department at the University of Iowa there have 
been performed 339 operative corrections rvith a postoperative folloiv-up ranging horn 
two months to a maximuni of twenty-two years. As the McBride and Brandes tecli- 
niques have only been used for the past four years, the series for these particular opera- 
tions is quite small. The following is an abstract of a talkie pi-esented by the author: 
The simple Silver osteoplasty produced good results in 79 per cent.; excluding the ar- 
thritics, good results were obtained in 87 per cent. The Mayo osteoplasty gave good 
results in 91 per cent.; with arthritics excluded, 92 per cent. With McBride and 
Brandes osteoplasties good results were obtained in 86 and 67 per cent. 

In conclusion the author states that congenital anomalies play only a minor role in 
the production of hallux valgus. Extrinsic forces (improper shoes, etc.) contribute 
directly in most cases to the formation and the recurrence of hallux valgus. Conserva- 
tive treatment improves many early cases. Simple coiTection of the e.vostosis without 
correction of the deviation (if not over 15 to 20 degrees) is the most logical treatment in 
women who wish to wear dress shoes. In the absence of arthritic changes the Silver and 
McBride operations are the best. Where arthiltic changes are present, the Mayo 
osteoplasty is apparently the best. Associated small toe deformities should be corrected. 
Metatarsus primus varus of from 15 to 20 degrees should be corrected along witli the 
hallux valgus, base correction being more logical and affording better results than shaft 
osteotomy . — William R. Malony, Jr., M.D., Iowa City, Iowa. 

Pneumorobntgenography in the Diagnosis of the Lesions of the Knee Joint- 

A. Lachowicz and M. M. Goldman. Polski Przeglad Radjologiczny, X and XI, 35, 

1936. 

The authors use an improved technique of pneumoroentgenograph j' and presen a 
series of excellent x-rays demonstrating the possibility of diagnosis in cases of injuiy o 
the menisci, in Hoffa’s disease, in cases of intra-articular free bodies, and in inflammatorj 
conditions of the synovia. They also mention the diagnostic possibilities in ostra 
chondritis dissecans and chondropathy of the patella . — Emamiel Kaplan, J • •> 
New York, N. Y. 

Osteomyelitic Involvement of the Shoulder and Hip Joint. M. Schieber. 

Polski Przeglad Radjologiczny, X and XI, 92, 1936. 

In a personal investigation of several cases, the author found characteristic ciangc^ 
in osteomyelitis of the hip and shoulder. There are early small foci of decalci 
sometimes revealing the presence of minute sequestra and a very mild periosteal reac lo ^ 

If the process begins in the acetabulum, small excavations filled with sequestra 
The roof of the acetabulum usually remains intact, the most frequent complication ic 
the separation of the epiph 3 'sis, followed bj' destruction and dislocation. Simi ar c inn 
were observed in the shoulder joint . — Emanuel Kaplan, M.D., New York, N. 

THE journal of BONE AND JOIST SVItOT 







260 


CURRENT LITERATURE 


4. Arterial paralj'sis is a consequence of arterial-trunk injuiy. 

This fundamental conception forms tlie basis for arteriectomy, as practised in these 
cases. Eitlier arteriectomy or arteriotomy for embolectomy may release the arterial 
paralysis and so prevent gangi'cne . — Henry Milch, il/.Z)., New York, N. Y. 


PiBD EOT ET HEMiPLEGiE FiiusTE (Club-Foot and Unsuspectcd Hemiplegia). Andr 6 
Thomas. La Fresse Midicale, XLV, 1333, 1937. 

Attention is called to the fact that club-foot may be due to an unsuspected hemi- 
plegia. This maj’^ be brought to light by careful e.vamination of the tonicity of the 
muscles, 63 ’^ the response to stimulation, b 3 ’^ the voluntary or involuntarj’’ motilit}’' of the 
involved extremit 3 q etc. In the very mild cases tliese observations ma}’’ be made, even 
in the absence of an}’’ reflex signs of p 3 ’’ramidal-tract involvement . — Henry Milch, M.D., 
Neiv York, N. Y. 


CoNSiDliRATioNS SUR LES RHEUHfATiSMES ET LEUR TRAiTEMENT (Rheumatism and Its 
Treatment), J. Le Calve. La Pi-essc MMicalc, XLV, 1409, 1937. 

The author has treated 155 cases of all t}’’pes of “rheumatism” on the basis of a 
sulphur deficiency, associated with a hypovitaminosis. These include twent}^-four cases 
of sciatica, acute articular rheumatism, psoriatic arthropatlyq chronic rheumatism, acute 
infectious rheumatism, etc. The percentage of satisfactory results is not given. 

The treatment consists of a diet rich in vitamins, sulphur injections, and autohemo- 
therapy, — twent}’’ cubic centimeters every four to five da 3 ’s . — Henry Milch, M.D., New 
York, N. Y. 


Osteoses et p^riostIjoses par carence alimentaire chbonique (Osteosis and Pen- 
osteosis Due to Chronic Alimentary Deficiency). G. Mouriquand, H. Tete, et 
P. Viennois. La Fresse MSdicale, XLV, 1419, 1937. 

In an earlier work the authors showed that it was possible experimentally to repro- 
duce the syndrome of chronic rheumatism by dietary deficiency. In the present essay 
they show that, in contrast to animals submitted to a total scorbutic diet, animals which 
were given diets only partially deficient in vitamin C preserwed a state of relative eutro- 
phia. They developed the typical osseous tumefactions due to subperiosteal hemor- 
rhages. If treated within the first twenty-five days, these tumefactions disappeared. 
If the experiment was persisted in longer, the tumefactions gradually ossified and w ere 
associated with articular stiffness, clinically resembling an ankylosing arthritis. Henry 
Milch, M.D., New York, N. Y. 

The Value of the Oblique View in the Radiographic Examination of the Lumbar 
Spine. S. A. Morton. Radiology, XXIX, 568, Nov. 1937. . 

This projection, called the Dittmar position, is made as follows; The patien rs 
placed on a flat Bucky table, with the legs extended, and is raised 45 degrees towar 'C 
side to be examined, — that is, if the right facets are being examined, the left side is raise . 
Sand bags steady the patient in position. The exposure will be about two and one- la 
times that given for an anteroposterior projection. 

The superior and inferior articular processes should be well shown and the Z 3 ga^ 
pophyseal joints definitel}" outlined. Pointed or irregular ends of articular 
indicate patholog 3 L The “pars interarticularis ” — that part of the posterior arc 1 ^ 
the lamina and inferior articular process join the base of the pedicle and 
process — is a vulnerable region and can be visualized adequately onty in the o 3 1 

Separations in the neural arch of the last lumbar vertebra, as in spondylolisth^os^^' 
are best shown in the oblique view, which also helps greatly' in deciding whet 
separation is possibly' due to trauma. Subluxations of the zygapophyseal join s an 

THE JOURNAL OF BONE AND JOINT SURGE 



CURRENT LITERATURE 


261 


degree of subluxation are best seen in this projection. It is often possible in this position 
to get a view straight through at least the upper part of a sacro-iliae joint . — Edward N. 
Reed, M.D., Santa Monica, California. 

Las par-ausis del nebauo cubital en las fractdhas del codo (Paralysis of the Ulnar 
Nerve in Fractures at the Elbow). Vincente Sanchis Olmos. Revista de Cirugia de 
Barcelona, XII, 82, 1936. 

In the histories of 600 cases of fracture at the elbow, fortj^-two (7 per cent.) were 
found in which the ulnar nerve was affected, either alone or with other nerves. There 
were twenty supracondylar and six epitrochlear fractures, eight fractures of the external 
condyle, one fracture of the olecranon, and seven fractures of other types. Six patients 
had paraesthesia but no loss of sensation or paralysis. Twent3"-two had paralysis in 
part of the ulnar distribution, and fourteen had complete paralysis. 

Treatment consists of prompt reduction of the deformity and skeletal traction where 
it is possible. Surgical intervention is necessary' where serious nerve injury' is suspected 
or where nerve involvement is present after the fracture has been corrected. Si.v pa- 
tients had operations. One had contusion of the nerve and subperineural hemorrhage. 
In two patients a pseudoneuroma developed from chronic contusion in abnormal posi- 
tion. One patient had no change at the level of the fracture, but the nerve was com- 
pressed in fascial scar at a lower level. Two patients were cured and four were im- 
proved . — Edward Francis Keefe, M.D., Brooklyn, New York. 

The NoN-OPERATira Treatment of Fractures and Dislocations of the Spine. 
Edward Thomas Newell. Southern Medical Journal, XXX, 799, Aug. 1937. 

Spinal fractures are often overlooked in the first week after an injury. They should 
alwaj's be suspected and looked for. Fractures of the cervical spine are treated by 
head traction and hj'perextension 63’’ means of a head halter and weight and pulley. 
This treatment is followed by the application of a plaster cast. Fractures lower down 
the spine are treated on a hyperextension frame with or without traction, followed b3’’ a 
plaster jacket for three to six months, then a back brace for six months or longer. — 
Fred O. Hodgson, M.D., Atlanta, Georgia. 

The Surgical Treatment op Low Back Pain and Sciatica. Ralph K. Ghormley 
and Harrison R. Wesson. Southern Medical Journal, XXX, 806, Aug. 1937. 

The authors have reviewed all the cases of low-back pain treated by bone-fusion 
operations at The Ma3'0 Clinic. They conclude tliat a fairly high percentage of cures 
can be obtained by fusion of the lumbosacral and sacro-iliac joints, hlore accurate 
diagnostic methods are proving of greater help in selecting cases for operation . — F red G. 
Hodgson, M.D., Atlanta, Georgia. 

A Review of Cases of Congenital Dislocation of the Hip Treated .at the 
North Carolina Orthopedic Hospital. W. M. Roberts. Southern Medical 
Journal, XXX, 987, Oct, 1937. 

This is a review of forty cases, and the author advocates the application of prelimi- 
nary traction before doing an open operation. This he thinks has facilitated the opera- 
tion, reduced the time, and lessened the danger of tr.auma to the head of the femur. 
The choice of cases for open or closed reduction is not made according to age, but accord- 
ing to clinical and roentgenographic findings. In the mnjorit3' of cases of open reduc- 
tion, some sort of shelving operation is also done. 

There were eight recurrences after reduction — two after open operation, and six after 
closed reduction. Si.xty-four per cent, of the cases showed some changes in the femoral 
head after open reduction, and 60 per cent, showed similar changes after clo.-ed reduc- 
tion. In the cases in which closed reduction was done better end re.-ults nerc obtained 
than in the cases in which open reduction was done. This ma3' be due in part to the higher 
age incidence in the latter cases.— Fred G. Hodgson, M.D., Atlanta, Georgia. 


VOL. x.x. NO. 1, JANt’AUA' I 03 S 



262 


CURRENT LITERATURE 


A Case of Alternating Scoliosis with Prov’en Etiology. Robert A. Milliken. 

Southern Medical Journal, XXX, 1099, Nov. 1937. 

The author reports tlie case of a ivoman, twenty-four years of age, who complained 
of pain in the right hip and leg of seven montlis’ duration. She gave a history of a fall 
one month previous to the onset of symptoms. Various types of treatment had been 
tried without relief. Examination revealed a slender woman with extreme left sciatic 
scoliosis on standing. Marked flattening of the Jumbar curve and forward leaning of the 
body from the hips were noted. She could bend forward freely, but attempts to stand 
erect caused a great increase in pain in the right leg down the sciatic nerve to the knee. 
When supine, tlio patient involuntarily shifted to a right scoliosis. At operation the 
spine of the first sacral segment was found to bo abnormally long and hook-shaped, 
extending upward to meet a correspondingly long spinous process of the fifth lumbar 
segment which had a cartilaginous elongation. The two processes were not joined, 
but were in contact even in the flexed operative position. Extension of the spine made 
■the processes slip bi’- one another, and a slight twist of the pelvis could make them overlap 
on one side or the other. This caused an alternating scoliosis. Spinal fusion of the 
fourth and fifth lumbar vertebrae and the sacrum was done. One year later the patient's 
back was normal . — Fred 6. Hodgson, M.D., Atlanta, Georgia. 

Early Weight Bearing in Fracture Dislocation of Ankle Joint. Aaron H. Trynin. 

Surgery, Gynecology and Obstetrics, LXV, 379, Sept. 1937. 

The writer sets forth three objectives in the treatment of these fracture-dislocations: 
(1) reduction; (2) maintenance; (3) functional return, the time and degree of which de- 
pend upon the former two plus early weight-bearing. Reduction and maintenance are 
accomplished by methods described by Bohler. Weight-bearing with a cane is started 
within a few days after the application of the non-padded cast and walking iron. The 
use of crutches is not permitted. Recurrence of displacement is not encountered. A 
period of from eight to ten weeks of walking in plaster is followed by from two to three 
weeks of physiotherapy. Apparently the same procedure without true early weight- 
bearing adds two to three months to the treatment period . — Richard McGomey, M.D-, 
Santa Barbara, California. 

Fractures in Children. J, Deu'ey Bisgard and Lee Martenson. Surgery, Gynecology 

and Obstetrics, LXV, 464, Oct. 1937. 

The writers present some clinical and experimental studies with conclusions con 
eerning the influence of trauma, particularly fractures, on the epiphyseal cartilage. 
hundred and thirty-two fractures of long bones in children were reviewed. In forty-mne 
the epiphyseal cartilage was involved. Only twent 3 ’’-eight cases were followed oyer a 
year. Eight of these patients had deformities due to growth disturbance. 'The au lors 
estimate that in 10 per cent, of fractures in children the epiphyseal cartilage is invo \ e • 
Most growth disturbances are insignificant. Of the 232 fractures, 3,5 per cent, presen ec 
demonstrable deformities due to growth disturbance. Whenever infection was 
growth was arrested. Repeated manipulations increased the incidence of grey ^ 
disturbance. It is preferable to be content with a reduction less tlian anatomica 
to do multiple manipulations or open reductions. Four out of five of the cases m ^ 
open reduction was done sliowed changes. Internal fixation penetrating the cai 
is practicalh'’ certain to produce growth arrest. Experimentation was 
3 'oung goats, and the growth clianges were noted . — Richard McGovney, A • •> 
Barbara, California. 


BUnOERV 


THE JOURNAL OF BONE AN'I> JOI.NT 



VOL. XX, NO. 2 


APRIL, 1938 


Old Series 
Vol. XXXVI, No. 2 


The Journal of 
Bone and Joint Surgery 


THE PRESIDENT’S ADDRESS 

A Plea for the Fundamental Principles of Orthopaedic Surgery * 

BY A. BRUCE GILL, M.D., PHILADELPHIA, PENNSYLVANIA 

Fellows of the American Academy of Orthopaedic Surgeons: It is a 
great honor to stand here to address you as your President. This Acad- 
emy has justified the foresight and the vdsdom of its founders and today 
constitutes the largest body and one of the most important organized 
groups of orthopaedic surgeons in the world. 

I feel your power and enthusiasm and ambition. I can gain a 
glimpse of the tremendous possibilities of your future. You have made 
me your leader for the moment. How should I attempt to counsel jmu; 
whither should I try to guide you? 

Should I attempt to instruct you in knowledge? You could teach 
your President many things. Should I point out to you new fields of 
endeavor? Your own genius is constantly driving you into these un- 
explored realms. Should I stimulate you to greater accomplishment? 
You are even now bursting with energy and ambition. How then shall I 
address you? Is there anything of myself that I can give to 3mu, whether 
you accept it or not? 

As an older man than many of you who are sitting before me, as one 
trained in the old and more conservative methods of orthopaedic surger}" 
and 3'^et familiar with the new, as one with a little longer experience and 
pos.siblj'^ a certain judgment gained therebj', I maj’- serve for j'ou as a 
bridge between the past and the present, as can also ni}' contemporaries 
here. What is has grown from what was. Not all of our older methods 
and experiences were useless; not all of our present ones liave j'et been 
tested and proved b^" time. 

Wo should not forget that the orthopaedic surgeon made a useful 
place for himself and his art, often in face of ojijiosition In' tlie general 
surgeon. He observed the laws of growth and repair; he studied jiin'sical 

•Rc.nd at the -Viinual Meeting of tlic .Vincrican .-Vcadciny of Orthopaedic .^urgeons, 
Los .Angeles, California, .lamiary IS, 103S. 

•-’0.3 




264 


A. B. GILL 


and mechanical principles in their application to the human body; he 
learned the value of rest and the moans to secure it in the presence of in- 
flammation. Above all, he stressed the function of the body, its preserva- 
tion and its restoration, as the ultimate end of all treatment. He never 
for a moment lost sight of this. Treatment of a case might continue 
through months and years, but at the very beginning he had a clear men- 
tal picture of the final result to be accomplished. Surgical operations 
Avere employed, but they were often only an interlude between the pre- 
operatiim and the iiostoperative phases of the treatment. He Avas skilled 
in manipulation Avith his hands and used the knife as a last resort. He AA^as 
thoroughly coiiAmrsant Avith the A’^alue of physical therapy and the indica- 
tions for its use. 

Surgery, as deriAmd from tAvo Greek Avords, means to AAmrk Avith the 
hands. In a broad sense a surgeon is one Avho practises the healing art 
Avith his hands, — Avhether it be by massage, by manipulation, or by the 
use of instruments and appliances. HoAveAmr, since the advent of asepsis, 
the skillful use of the knife has become, properly or improperly, the dis- 
tinguishing talent and criterion of the great surgeon; and there has been 
a groAAung tendency to neglect, to delegate to persons Avho are not members 
of the medical profession, and CAmn to discard entirely all the arts of 
surgery but the use of instruments and mechanical apparatus. 

Directly and indirectly because of these self-limitations of the modern 
surgeon, there have arisen various schools of therapy and thousands of 
practitioners Avhom Ave choose to call irregular because they are outside 
the ranks and beyond the control of the organized medical profession. 
Strange to relate, many of them — ^such as the bone-setter, the chiroprac- 
tor, and the osteopath — claim to heal by the use of their hands ; and to our 
surprise and astonishment, to our embarrassment and chagrin, they 
succeed at times Avhere Ave fail. 

In this mechanical age there has been a tremendous production of all 
kinds of laboratory devices and of machines, instruments, and apparatus 
for the diagnosis and the treatment of medical and surgical conditions. 
Consequently, there has been a marked tendency among medical students 
and practitioners to rely upon these aids rather than upon their OAvn 
natural poAvers of observation and the skillful use of their hands. Do avc 
not like too Avell to shift the responsibility of diagnosis upon the labora- 
tory technician and the roentgenologist? And do Ave not accept too read- 
ily the assurances of salesmen that their costly electrical machines aai 
heal all kinds of disease and that their complicated apparatus Ai'ill cure 
all fractures? Let us not forget that our hands are the finest and most 
cunning instruments eA^er made. Do AA'^e persistently cultiAmte theii s vi 
in diagnosis and treatment? 

There is some resemblance today betAveen the changing conditions m 
Medicine and Surgery and those in Society and the Body Politic. 

The course of the arts and sciences has ahAmys been related m a 
general Avay to social and political order. During periods of upheaA a , 

THE JOURNAL OF BONE AND JOINT SUROnBA 



president’s address 


265 


of oppression, and of tyranny they have languished, but when a great 
crisis has been successfully passed and peace, quiet, and order prevail they 
have flourished. The Greek genius, unsurpassed in the history of the 
world, that sprang up as naturally and as universally as flowers in the 
fields, reached its greatest heights after the Persian Wars. The Golden 
Age of Augustus followed the civil wars of Rome and the consolidation of 
the empire. The Elizabethan Era came after the Spanish menace had 
been beaten back and England had entered upon her long and glorious 
history of freedom and wealth. The American War of Independence and 
the French Revolution brought to the citizen relief from oppression by 
the State and the Church and opened the gates to Science which since 
then has made unbelievable advance. 

Then came the Great War which again stirred the world to its 
depths, and we are now at the beginning of another period of change and 
readjustment. There is a striving for some new and different freedom, 
a freedom from poverty and want and worry and anxiety both present 
and to come, a relief from oppression by class and by wealth and power of 
individuals and groups of men and corporations. And there is much con- 
fusion of thought, of purpose, and of methods. There seems to be too 
great an inclination to discard the old and to try the new, no matter what 
or how unproved by time and experience. The lessons of history may be 
forgotten, the fundamental principles of human nature, which are the basis 
of individual conduct, of social relations, and of law and order, may be 
overlooked. 

Some peoples have lost faith and confidence in their own powers to 
reach the ideal and have surrendered their individual rights and liberties 
to a dictator who promises them national and individual security. To 
attain a new end they have forgotten and have lost that for which our 
forefathers foifght, the inalienable rights of the individual which no state 
or form of social organization can take away by force or accept by sur- 
render of the majority. As long as one man lives in whom breathes the 
spirit of liberty and of justice, the freedom of the human soul cannot be 
destroyed. Disaster to medicine, art, music, letters, science, and religion 
has followed swiftly upon the lo.ss of individual freedom. 

We must not forget in this present period of confusion and rapid 
change that there are fixed, established, and undjung principles of right 
and of liberty proved by centuries of happy experience, and we must not 
sacrifice these in the hope of gaining some new end, good though this end 
may be in itself. It will prove but a false dream that lures us to destruc- 
tion. There are no "New Deals” and "New Eras” unrelated to the past 
and essentially different from them. There are no new principles of right 
and wrong, of freedom and oppre.=sion. The virtues and the vices of men 
persist, and it is difficult to see that there is less selfishness, less grasping 
for jiower, less enmitj', and less strife to possess that which belongs to 
another than in times gone by. 

It cannot bo denied that there is tins dccj) unrest in the world today, 
voi.. XX. xo. 2. Ai’nii. 10.1“: 



266 


A. B. GILL 


this striving upward for sometliing which may vastly benefit civilization, 
ill-defined and chaotic as this urge may bo. As men of intelligence and as 
physicians we cannot ignore it and cling pertinaciously to the past or drift 
idly with the current. We must aid in finding solutions to these new prob- 
lems, which, however, may not be attained in our generation, Bdthont 
selfishness, injustice, strife, violence, and tyranny either by the minority 
or by the majority, and without loss of individual liberty and the right of 
property upon which our whole civilization rests. 

Howeimr, apart from these general but vital considerations, I think 
I can see in our own particular profession some evidence of this same 
spirit of unrest. There is some tendency to discard the older and con- 
servative methods in surgery, many of which required time and patience 
and exact attention to details, and to adopt almost overnight, as it were, 
newer methods which promise much but ivhich have not yet stood the 
test of time. The former require intimate knoivledge of anatomy and 
physiology and the mechanics of the body. The latter may require only 
skillful operative technique; New operations or modifications of old ones 
have appeared by the score, — some to be found useful and to become 
classic, many soon to be discarded and forgotten. 

There appears to be a tendency to neglect the study of the funda- 
mentals of surgery and to place our sole reliance upon methods and fads 
and gadgets. Consider how many appliances there are for the reduction 
and immobilization of fractures. It has become the vogue, I might al- 
most say the fad, at the present time to employ them almost entirely and 
to the exclusion of the older methods of reduction and fixation. Most of 
them are unnecessary to the surgeon who is familiar with the simple laws 
of mechanics, wdio is versed in the principles of fractures, and who has 
acquired sldllful use of his hands in manipulation and in the application 
of fixation dressings. To treat all fractures by a certain rule and by some 
special apparatus, as if the rule supplanted the use of the brain and the 
apparatus that of the hands, is both ridiculous and futile. I wage no war 
against gadgets in themselves. They often delight one with their neat- 
ness, their mechanical nicety, and their efficiency in saving of time and 
energy. However, I do object to their indiscriminate use without a 
thorough understanding by the surgeon of the problem which confronts 
him, of the precise way in which the mechanical apparatus works, of what 
it may be expected to accomplish, and of any possible dangers or comp i 
cations attendant upon its use. Moreover, the surgeon should be ceitain 
that its use will give him better results than he was able to obtain with t le 
old and familiar methods. The body is a complicated machine an i 
requires a skilled mechanic to repair it. The surgeon uses his hands an 
employs tools "with which he is familiar and which he know^s will a,ccom _ 
plish his definite purpose. If he has no efficient tools he may even im en 
a ne^v one. 

Let us, however, beware of adopting new methods too hasti y. 
recall how’' a few years ago Sir Arbuthnot Lane taught the open re uc i 

THE JOURNAL OF BONE AND JOINT SURGER 



president’s address 


267 


and plating of all fresh fractures. His dicta in time were accepted by 
many surgeons in all countries. In the practice of his method not all of 
these surgeons were as meticulous and skillful as Lane himself, and many 
cases of osteomyelitis, non-union, and malunion occurred. Then we 
learned again what we knew before, — that most fractures can be efficiently 
treated by closed reduction and skillful fixation. A method used success- 
fully by one surgeon may be unsuccessful in the hands of another by 
reason of some ineptitude and lack of full understanding of the principles 
involved. 

As another illustration, consider the history of the treatment of bone 
and joint tuberculosis. If we accept as true the conception that tuber- 
culosis is a general disease mth a pronounced local manifestation, but 
with the presence of the tubercle in other places and structures of the body, 
and that its development is due to a weakening of the resistive processes 
of the body, then the various methods of the treatment of the local mani- 
festations of the disease in bones and joints vdll fall into their true per- 
spective. Chronic disease is to be stayed or'cured by forces resident in 
the body itself. Local rest by fixation is but one means of aiding nature 
to cure the local focus. Whether or not we use prolonged recumbency 
mth traction, or plaster casts, or splints (how few of us have the patience 
and skill of a Hugh Owen Thomas!) or whether we resort to surgical opera- 
tion may depend on our own experience and skill. We must, however, 
recognize that none nor all of these methods of fixation of the diseased joint 
in themselves and by themselves promise infallible cure. Nature’s own 
forces must be rallied to turn the battle against the invading disease. I 
decry the indiscriminate employment of biopsy and of surgical operation 
in the diagnosis and treatment of bone and joint tuberculosis. Present 
teachings must be viewed in the fight of past experience and judged vnth 
full knowledge of the principles which underlie the treatment of chronic 
disease. 

Are too many operations performed in the practice of Orthopaedic 
Surgery? Is there too great a tendencj’’ to discard the old and to take up 
the new or to proclaim as new that which was tried 3’^ears ago? In recent 
years operative procedures have been multiplied in our branch of Surgery 
more rapidlj’- than in anj’- other division of Su^ger3^ i\Ian3’- of our 3mung 
men believe that tlie3'^ can attain distinction onl3’' b3’' the invention of a new 
operation. 

Successful invention can come onl3’' after thorough famifiarit3’’ with 
the old, its uses and its defects and weaknesses. It seems evident to man3' 
of us that surgical procedures are often emplo3'ed b3' surgeons who are not 
thoroughl3' familiar with the methods of conservative treatment and who 
are unacquainted with their possibilities. Fusions of the lumbar spine 
and of the sacro-iliac joints arc performed to cure chronic backache when 
the cause and the origin of the pain are not clearh' determined. The re- 
sult is that man3' of these ojicrations have not relieved the pain for which 
thc3' were performed. No operation should be done except for definite 


VOL. XX. -VO. ;. ArniL loss 



268 


A. B. GILL 


and logical reasons, unless it should be an experimental procedure done as 
a last resort. 

Some operations arc performed which do not offer suflScient restora- 
tion of function to justify the operative risk. A moderate shortening of 
an extremity as the result of infantile paralysis may not in itself constitute 
a severe handicap to the patient. The amount of functional improvement 
to be secured by leg-lengthening may not balance the surgical risks at- 
tendant upon it. It is a primary principle of surgery that no operation 
should be undertaken routinely, but only after careful consideration of all 
the factors — physical, mental, social, and economic — that enter into the 
problem. We must not forget that our specialty was founded in the spirit 
of conservatism. 

You are like a youthful army surging forward. I would counsel you 
to avoid misapplication and waste of energy, to exercise restraint at 
times, to curb rashness with sound judgment, to strike a fair mean be- 
tween conservatism and radicalism, to see the truth written on both sides 
of the shield, to refrain from fads and fancies, to seek the eternal truth 
beneath the changing surface, to distinguish fountains of living water 
from the mirage. Study principles rather than methods. A mind that 
grasps principles will devise its own methods. Read history and reflect 
upon the experiences of the past that you may perceive those things that 
have proved their worth through the years and the centuries and be en- 
abled to avoid the pitfalls of the present and the future. 


THE JOURNAL OF BONE AND 


joint SUROEn'i 



OPPOSITION OF THE THUMB * 

BY STEELING BUNNELL, M.D., SAN FRANCISCO, CALIFORNIA 

A great asset to man is the opposable thumb. The hand so useful to 
all and the livelihood of the manual worker owes much of its efficiency to 
this pincer action of the thumb. 

Opposable digits are not new in nature. Most birds have them. The 
digits of the African chameleon directly oppose each other around a branch 
and as far back as the crustaceans there are opposing claws of crabs and 
lobsters. 

In mammals the opposable thumb is found only in the primates and 
starts with the lowest forms of them, the lemurs. The more arboreal is 
the monkey, like the gibbon, and the more developed its prehensile tail, 
as in the western hemisphere, the smaller and less opposable is its thumb, 
so the spider monkey is even thumbless. A hand without opposition of 
the thumb has been called “ape hand”, but this is an injustice to the apes 
as in their hands opposition is well developed and it is even more so in their 
great toes. In man locomotion has been confined to the feet, leaving the 
hands free to develop handiwork. The pollex has thus become more 
opposable and the hallux has lost its power of opposition. 

DEFINITION AND DESCRIPTION 

The term “opposition” is from the Latin “ opposiiio” meaning 
opposite. It implies opposite and far apart like the opposite points in a 
circle. In astronomy when two heavenly bodies are 180 degrees apart 
they are said to be in opposition. 

The thumb to be in true opposition must not only be opposite the 
fingers and far forward from them, but it must also be bj'^ rotation dia- 
metrically opposite to them, — that is, with the pulp of the thumb facing 
that of the fingers and with the thumb nail parallel to the palm or volar 
surface of the fingers. Also, in the motion of fle.xion and extension, the 
thumb and the opposing digits should move in exactly opposite directions 
to each other. 

Merely placing the thumb into appo.sition — that is, in contact with 
the fingers — or drawing it into the palm is not opposition, nor is it when 
the thumb fails to rotate and its nail is still at a right angle to the palm. 

R.\NGE OF MOTION OF THE THUMB 

Normallj'^ the thumb can touch the palm in its distal and radial 
margins, as well as all of the fingers over most of their surfaces, although 
this is increa.singly Ic.ss possible on their dor.-al and ulnar aspects as the 
thumb reaches from the index to the little finger. The thumb can also 

* Read at tlic .•Viiiuial Mcctinp of tlic .American .Academy of Ortliojwaiic .“'iirceotis, 
Los .Anpele.s, California, .Taniiary UO, li>.'!S. 


VOI.. ,VX, NO ", ACItlL lO.IS 


209 



270 


STERLING BUNNELL 



Hands of man and monkeys. Those with the most opposable thumbs are, in or- 
der: man, gorilla, baboon, chimpanzee, and orangutan. The more ground dwelling 
is the monkey, the better developed is the opposable thumb; the more arboreal, the 
less thumb it has. The more prehensile is the tail, as in new-world monkeys, the 
less use the animal has for a thumb, until the spider monke}’' has none at all. {Cour- 
tesy of the American Museum of Natural History, Nem York, N. Y.) 

pass backward over the radial border of the palm to reach the plane of the 
dorsum of the hand. From here it can abduct from the hand to about a 
right angle and then sweep forward from the hand in a semicircle until it 
touches the base of the little finger. Let us observe the thumb in its excur- 
sion through this forward arc. At the start, the thumb and thenar emi- 
nence form a cone protruding laterally from the hand. When midway in 
the path of the semicircle, this cone projects forward from the hand, and 
the thenar crease is folded to a right angle. If we ivatch the thumb again 
through this arc, we will see that at the start the nail is at a right angle to 
the palm, and the thumb bones are in a straight line as seen from behind. 
In traversing the semicircle these relations are maintained and a certain 
strain is felt in the thenar eminence until, as the first third is completed, 
the strain leaves, the nail starts to rotate in pronation, and the proximal 
phalanx angulates radially on the metacarpal. As the change occuis, 
the muscles in the radial half of the thenar eminence conspicuously spring 
into action and continue the motion. The strain occurs when the ad- 
ductors are fully stretched by the long extensors of the thumb. The 
adductors insert on the ulnar side of the proximal phalanx and, when under 
tension, tend to supinate, but are opposed by the muscles attached to 

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OPPOSITION OF THE THUMB 


271 



Fig. 1-B 


Feet of man and monkeys. In man the feet are used entirely for locomotion, so 
that the hallux has entirely lost the power of opposition and the pollex has devel- 
oped it. All monkeys have an opposable hallux far better developed, with the 
exception of the gorilla and the baboon, than is the pollex. [Courtesy of the 
American Museum of Natural History, New York, N. Y.) 

the radial side of the phalanx, principally the outer head of the short 
flexor. The latter pronates and, after pronation is started, also ungulates 
the phalanx radially. The strain is relieved just as the adductors are 
relaxed and the short flexors have their way. Throughout the arc the 
long extensors maintain the necessary stabilization in extension of the 
three joints of the thumb. 

The motion of opposition takes place in the intercarpal, carpo- 
metacarpal, and metacarpophalangeal joints. This motion is of two types 
— angulatory and rotary — and all three joints contribute to each. 
The carpometacarpal joint furnishes most of the angulatory motion and 
the metacarpophalangeal joint most of the pronator}’’ motion. The sum 
of the angulatory movement in opposition is shown in the distal segment 
of the thumb which angulatcs through an arc of about 120 degrees, and 
the sum of the pronatory movement is shown in the plane of the thumb 
nail which rotates 90 degrees from a position at a right angle to the palm 
to one parallel with it. In Figures 2-A through 3-B toothpicks are attached 
to the skin to show better the movements in each segment of the thumb. 

The intercarpal movement increases the carpal arch and takes place 
by the movement of the greater multangular on the navicular and the 
lesser multangular and by the movement of the latter two in turn on the 
capitate. This is readily demonstrated by the inability to oiijio.-e the 


VOI., X.X. XO. C. M'lm. IP’!': 





OPPOSITION OF THE THUMB 


273 


With the wrist dorsiflexed and the thumb in opposition, the cleft open 
for grasp between the thumb and the palm is then in direct line with the 
forearm as it should be. Opposition aids in forming a circle with the 
thumb and index finger and an ellipse with the thumb and little finger. 

The degree of opposition may be expressed by the distance which the 
pulp of the thumb reaches in front of the base of the long finger and also 
by the pronatory angle or the plane the nail makes with the palm as com- 
pared in each instance to these measurements in the normal hand. Thus, 
opposition in a hand may be expressed as one inch and 45 degrees of 
angle, compared with three inches and an angle of zero, which are the 
similar measurements taken for comparison in the other or normal hand. 

CAUSES OF LOSS OF OPPOSITION 

Loss of opposition results from loss of nerve function to the muscles 
of the radial half of the thenar eminence, or loss of these muscles them- 
selves, or it may be due to cicatricial contracture from infection which 
approximates the first two metacarpals, to adhesions which hold back 
the tendon of the extensor pollicis longus, or to flat-hand from faulty 
splinting or from ankylosis of the intercarpal and carpometacarpal joints. 

METHODS OF RESTORING OPPOSITION 

Opposition may often be restored, depending on its cause, by nerve 
suture, by excision of the cicatrix binding the first and second metacarpals 
or of adhesions of the extensor pollicis longus tendon, or by wedge oste- 
otomy in case of ankylosis of the carpus. In eleven cases the author has 
sutured the motor thenar branch of the median nerve to restore opposition. 
The motion returned in about thirteen months. In the writer’s series of 
eighty-three repairs of the median nerve by suture, opposition has been 
restored in 66 per cent. 

When the nerve or thenar muscles are irreparable and the mobilizing 
operations mentioned have been done if necessary, then tenoplasty b}’’ 



Fig. 3-.\ Fig. .>-15 

Views from flic front witli the thumb at the side of the hand and in full oppo- 
sition. Note the degree of pronalion of the segments of tlie fliumh made graphic 
by toothpicks. The nail rotates through 90 degrees. The greatest pronation 
occurs at the metacarpophalangeal joint. 


VOI.. .>CN, XO. 2. APHII. 103S 



272 


STERLING BUNNELL 



Fia. 2-A Fig. 2-B 



Fig. 2-C Fig. 2-D Fig. 2-E 


Tlie successive positions assumed by the thumb in transcribing its normal for- 
ward arc of opposition. Tlie toothpicks — one placed crosswise and parallel with 
the nail and three each vertical to a separate segment of the thumb — are to show 
more graphicly the angulatory and pronatory thumb movements. 

Fig. 2-A: The thumb starts at the side of the hand. The nail is at a right angle 
with the palm, and the vertical toothpicks are in line with each other. 

Fig. 2-B: After the first third of the arc has been traversed, the thumb com- 
mences to pronate. 

Fig. 2-C: The greatest pronation is between Figs. 2-B and 2-C. 

Fig. 2-D: Position of full opposition with the thumb well forward from ana 
opposite the base of the long finger, angulated toward the ulna, and with the nai 
parallel with the palm. Note the degree of pronation shown in the relative posi- 
tions of all four toothpicks. ., 

Fig. 2-E: The thumb, now past the position of opposition, is completing its mo 
and approaching the base of the little finger. 

thumb when the carpal arch is prevented from arching. The arching is 
produced largely by contraction of the thenar muscles which are attached 
to the transverse carpal ligament. The palmaris longus aids in t ns. 
The metacarpal is angulated and pronated on a saddle joint large y i>y 
the opponens pollicis aided somewhat by the abductor pollicis longus an 
the outer head of the flexor pollicis brevis. The proximal phalanx is 
angulated and pronated mostly by the outer head of the flexor pollicis 

brevis acting on a ball-and-socket joint. • • i 

The main antagonist to opposition is the extensor pollicis long ^ 
although this muscle also aids in the motion by its effect along with i 
extensor pollicis brevis and the abductor pollicis longus in stabilizing 
joints of the thumb in exten.sion. 

THE JOUnXAL OF BON'E AN'D JOINT SUnGER 



OPPOSITION OF THE THUMB 


275 


Ai^ 



tendon grafting will restore very good opposition if the following two 
major principles are adhered to. 

TWO ESSENTIAL PRINCIPLES OF TENOPLASTY 

The tendon from its insertion in the thumb should pass subcutane- 
ously in the direction of the pisiform bone, so that it will pull the thumb 
in the correct direction, and the 
insertion of the tendon should 
be on the dorso-ulnar aspect of 
the base of the proximal phalanx 
of the thumb, so as to restore 
the pronatory component. 

To make the tendon pull 
toward the pisiform bone, either 
a tendon pulley is constructed 
there or the tendon is looped 
around the distal part of the 
tendon of the flexor carpi ulnaris. 

There vdll then be a similar ar- 
rangement to that found ana- 
tomically in the omohyoid or the 
tensor veli palatini muscles. 

The first case in which the 
author used these principles was 
reported in Surgery, Gynecology 
and Obstetrics in September 1924. 

His series of forty-six cases has 
convinced him of the correctness 
of these principles. Many other 
methods have been reported by 
the use of which excellent re- 
sults have been claimed. From 
the illustrations in tliese reports, 
however, it is evident that the 
conception of true opposition 
was not as e.xpressed here. No 
operation where the tendon 
passes under the trans\’ersc car- 
pal ligament can possibly pro- 
duce true opposition, as the 
tendon does not pull in the right 
direction. It merely pulls the 
thumb into the palm and not out 
forward from it.* Also, if a 


Fig. 5 

A splint of adhesive plaster to hold the 
thumb in position of opposition. A small 
pad protects the skin. The resultant of pull 
by the two arms of adhesive is in the direction 
of the pisiform bone. This splint is useful in 
protecting paralyzed thenar muscles and newly 
placed tendons and in bending stiffened joints 

into this func- 
tionating posi- 
tion, including 
increasing the 
carpal arch. 



Fig. 6-A 


Fig. G-B 


Miss S. P. Restoration of opposition of 
the thumb by suture of the tiny motor 
tlicnar branch of tlie median nerve. In this 
c.ise the nerve was severed, as shown in 
Fig. 0-B, by surgical incision for drainage of 
the thenar space, which resulted in atrophy 
of the muscles and loss of opposition. The 
photograph was taken thirteen months hiter 
and shows tlie well-restored tiienar eminence 
and rci^toration of ability to oppo-o the 
thumb. 


* In some ca.scsof poliomyelitis, a.sObcr has suggested, the transverse carpal ligament 
is so lax that a tendon p.a.s.sed under it might pull the thumb toward the pisiform bone. 


VOL. N.X. NO, c. . 


.\rniL is.is 


274 


STERLING BUNNELL 








OPPOSITION OF THE THUMB 


277 



Fig. S-A Fig. 8-B 


Mr. W. W. Extensive laceration of the hand and wist eighteen months previ- 
ously in which the median and ulnar nerves and several tendons were severed. 

Fig. S-A: Complete thenar atrophy and loss of adduction and opposition of the 
thumb and loss of abduction of the index finger. 

Fig. 8-B: Extensive repair of nerves and tendons was done. Without waiting for 
the nerves to regenerate, the tendon of the extensor indicis proprius was sutured to 
that of the first interosseus muscle with restoration of abduction of the index finger. 
A pulley operation was then done on the thumb, in which the flexor carpi ulnaris was 
used as the motor power and a slip from it was used to construct the pulley. The 
tendon of the extensor pollicis brevis was withdrawn from the arm and transferred 
subcutaneously across the thenar eminence through the pulley and sutured to the 
flexor carpi ulnaris. In the photograph, taken only two months later, the tendon can 
be seen drawing the thumb two inches in front of the base of the index finger. 

Lyle employed the same method, but, in addition, combined it with 
Steindler’s operation on the flexor pollicis longus tendon. 

The followdng are methods using the flexor pollicis longus tendon and 
also keeping the tendon beneath the transverse carpal ligament: 

Steindler split the distal end of the fle.xor pollicis longus tendon in 
two and detached the radial half from its in.sertion, pa.s.sed it around the 
radial side of the thumb, and rein.serfed it at the back of the base of the 
proximal phalanx. 

Silfverskiold risked the use of the whole flexor tendon of the thumb, 
transplanted it around the radial side of the thumb, and inserted it at the 
base of the proximal phalanx. 

Whitchurch severed the fle.xor pollicis longus tendon, carried it 
around the radial side of the thumb, and resutured it. 

^'on Baej^er freed the insertion of the flexor pollicis longus, passed it 
around the radial side of the thumb, and reinserted it at its original 
insertion. 

In the following methods the extensor tendons are used: 

Jahn jia.s.scd the extensor tendon of the third digit around the ulnar 
border to the volar side of the hand and in.-^erted it into the first meta- 
carpal. He repaired the defect with a free fascial transplant. 


VOL. XX. XO. C. .M'UIL ItUv 




276 


STERLING BUNNELL 



Fig. 7-A Fig. 7-B 


Dr. E. S. Restoration of opposition of the thumb by suture of the median nerve 
at the wrist. 

Fig. 7-A: From laceration at the wrist, both median and ulnar nerves and several 
tendons were severed, resulting in claw-hand with atrophy of the thenar muscles 
and complete loss of opposition and adduction of the thumb. 

Fig. 7-B: Two years later function of the intrinsic muscles had been restored by 
suture of the median and ulnar nerves. The thenar eminence and other intrinsic 
muscle.s, as well as the ability to oppose the thumb, had been restored so that the 
patient was able to resume tlie practice of dentistry. 

tendon is used for opposition, it should be for that function alone 
and should not have two insertions, each for a different function. Other- 
wise there will not be free and independent action in each of the two 
functions. If a flexor is used, the thumb cannot be flexed without oppos- 
ing. The muscle transferred should be adequate in strength and its 
original function, if important, should not be sacrificed. 

OTHER METHODS REPORTED 

With these principles in mind, the author wishes to mention briefly 
the methods previously reported. 

The first group represents methods in which the tendon is passed 
under the transverse carpal ligament: 

Krukenberg split the flexor digitorum sublimis tendon of the long 
finger and inserted it in the radial half of the first metacarpal. 

Roeren did the same with the flexor digitorum sublimis tendon of the 
ring finger. 

Ney used the tendon of the extensor pollicis brevis detached above, 
and, after passing it under the transverse carpal ligament, joined it to the 
tendon either of the palmaris longus or of the flexor carpi radialis. 

THE JOURNAL OF BONE AND JOI.NT SUROER' 


OPPOSITION OF THE THUMB 


279 


Fig. 10 

Mr. P. C. A burn from a bot- 
tling machine destroyed the thenar 
eminence. This was covered by a 
pedicle skin graft. 

The ability to oppose the thumb 
was restored by a tendon-transfer 
pulley operation. The tendon of 
the extensor pollicis brevis was de- 
tached at its muscle, withdrawn 
through an incision at its insertion, 
and then passed subcutaneously 
across the thenar eminence toward 
the pisiform bone. The tendon of 
the palmaris longus was detached at 
its insertion, looped about the ten- 
don of the flexor carpi ulnaris for a 
pulley, and then sutured to the ten- 
don of the extensor pollicis brevis. 


Figs. 10-A and 10-B: Good oppo- 
sition restored. The tendon pulling 
beneath the skin is apparent. 


Fig. 10-C: Showing loss of the 
thenar eminence. 


Fig. 10-C 


Fig. 11 

Fig. 11-A: Mr. A'. H. The median nerve had 
been severed at the wrist and was sutured three 
years previously, but without return of the thenar 
eminence or ability to oppose the thumb. 


Fig. 11-B: Mr. A. H. A tendon-transfer pulley 
operation promptly restored ability to oppose the 
thumb as shown in the hand with the atrophied Fig. 11-A 

thenar eminence and the 
sleeve rolled up. 

The flexor carpi ulnaris 
tendon was split in two 
near its insertion. One 
half was used to make a 
pulley and the other was 
detached at its insertion 
and prolonged by a free 
graft from the tendon of 
the palmaris longus. This 
was passed through the 
pulley, across the thenar 
eminence subcutaneously, 
over the tiorsum of the 
proximal joint of the 
thumb, and attached by 
a drill hole to the base of 
the proximal phalanx at 

its (lorso-ulnar aspect. Fig. 11-B 

voi.. XX, xo. c, .\i’nii. itijs 











278 


STERLING BUNNELL 


Fig. 9 

Miss M. V. Following 
poliomyelitis at the age of 
four, the thenar muscles 
atrophied and the patient 
could not oppose the thumb 
at all nor could she flex it. 
Also the extensor pollicis 
longus ivas too weak. , The 
flexor digitorum sublimis 
of the ring finger was 
transferred to the flexor 
pollicis longus to furnish 
flexion. For opposition the 
palmaris longus, together 
with its extension, the 
palmar fascia, was passed 
through a pulley at the 
pisiform bone made from 
an extensor of the toe, and 
passed on subcutaneously 
to be attached to the ten- 
don of the extensor pollicis 
longus. This restored 
ability both to extend and 
to oppose the thumb. 

Upper: Limit of opposi- 
tion preoperatively. 

Middle: Tendon trans- 
fers. 

Loioer: Function of 
thumb, including restora- 
tion of opposition. 


Cook’s operation, 
as described by Tay- 
lor, consisted of pass- 
ing one of the extensor 
tendons of the little 
finger around the wrist 
subcutaneously and 
inserting it into the 
first metacarpal. 

Other miscellaneous methods are as folloyvs : 

Huber and Nicolaysen used the abductor of the fifth digit and fastenec 

it to the first metacarpal. _ 

Camitz inserted the tendon of the palmaris longus with some o le 
palmar fascia on the lateral side of the metacarpophalangeal joint o le 

thumb. _ . , , 

Kortzeborn used a fascial sling to fix the thumb in oppo.sition, i 
plastic operation on the palm, and lengthened the extensor tendons. 

Spitzy, and also Baldwin, jDerformed an arthrodesis on the carpo 
metacarpal joint of the thumb. 



THE JOURNAL OF BONE AND 


JOINT SURGEHI 






280 


STERLING BUNNELL 


Foerster planted a three-centimeter iDone graft from the tibia be- 
tween the first two metacarpals. 


TECHNIQUE OF OPERATION ADVOCATED 

If the two main essential principles mentioned are adhered to, one has 
quite a varied choice in the selection of muscle and tendon and in the con- 



Fig. 12-A 


struction of the pulley, depending on 
which are available or advantageous 
in tlie particular case of reconstruction. 
Each hand is a problem in itself, 
and, as the parts injured differ, so 
we must adapt our procedure to the 
available material providing we ad- 
here to these two simple principles,— 
nainely, direction of pull and correct 
insertion to give pronation. 

Any of the following may be 
available; 

For motor power, we may use the 
flexor carpi ulnaris, the palmaris lon- 
gus, the flexor digitorum sublimis of 
the ring finger, or any available long 
flexor muscle. The extensor muscles 




Fig. 12-B Fig. 12-C 

Mr. R. F. A porcelain faucet lacerated the thenar eminence, damaging the motor 
thenar branch of the median nerve beyond repair and thus paralyzing the abductor 
and opponens pollicis muscles, so that the patient could not oppose the thumb, uw 
flexor tendon and the two volar nerves of the thumb were also severed. I'our 
months later the flexor pollicis longus tendon was I’epaired by a free graft from tne 
palmaris longus tendon, and the two sensory nerves were sutured. A tendon- 
transfer pulley operation was done to restore opposition. The tendon of the ex- 
tensor pollicis brevis was detached at its muscle, withdrawn near its insertion, an 
then passed subcutaneously across the thenar eminence. Here it was passed tnroUo 
a pulley made from a free graft of the palmaris longus and was sutured to the tenc o 
of the flexor carpi ulnaris which was detached from its insertion for 
Fig. 12-A: Showing the ability to oppose the thumb to two inches in 
base of the ring finger and two and one-half inches in front of that of the long nng 
Fig. 12-B; The pronation and forward position gained. fl„vnr 

Fig. 12-C: Atrophj'’ of the thenar eminence. The original function of tne e. 
carpi ulnaris muscle has not been lost. 

THE JOURXAt. OF BON’E AND JOINT SURGErfi 



OPPOSITION OF THE THUMB 


281 


are rather weak for this purpose, and their course is long, thus presenting 
opportunities for the formation of adhesions. 

In regard to tendons, the extensor carpi radialis brevis is excellent as it 
already has the correct insertion, and also will retain its original function 


Fig. 13 

Mr. T. T. Abilitj’’ to oppose the 
thumb was lost by a wide e.xcavation of 
a dado saw through the thenar eminence, 
which destroyed bej'ond repair the mus- 
cles and motor thenar branch of the 
median nerve. 

Abilitj' to oppose the thumb was re- 
gained b}' a tendon-transfer pulley opera- 
tion, using the flexor carpi ulnaris mus- 
cle for the motor power. The tendon 
of the extensor pollicis brevis, which had 
been withdrawn from above, was passed 
subcutaneouslj' across the thenar emi- 



Fig. 13-A 



Fig. 13-B 



Fig. 13-C 


nonce and through a pulley at the pisiform bone. This pulley was constructed 
from a free tendon gnift of the palmaris longus and was sutured to the tendon of 
the flexor carpi ulnaris. The latter w.as iletached from its insertion at the pi-ifomi 
for the purpose, but did not lose its function as Ls shown in Fig. 13-C. Oppo'-itiori 
of the thumb was restored as shown in Figs. 13-.V and 13-H. The atnipliv of the 
thenar eminenct .shows in all three pictures. 

voi.. XX. xo. c. .\rnii. 10:1s 








282 


STERLING BUNNELL 


and can be sutured to another tendon just proximal to the pulley at the 
pisiform bone. Also, the palmaris longus can be prolonged sufficiently by 
using its prolongation, the palmar fascia, or any tendon desired can be 
pieced out by a free tendon graft either from the palmaris longus ten- 
don or from any other tendon that may be available. 

For the construction of a pulley at the pisiform bone, a free tendon 
graft either from the palmaris longus or from any other available tendon 
can be looped through the short muscle and tendon attachment to the 
pisiform bone and sutured to itself, so that it forms a circle two centimeters 
in diameter. The sutured junction is then slipped around until it is 
within the muscle. 

Another method of making a pulley is to use one-half the thickness of 
the flexor carpi ulnaris tendon, severing one of the halves high and sutur- 
ing this free end to the ligament of the pisiform bone to complete the loop. 

Similarly, the tendon of the palmaris longus can be severed four 
centimeters above its insertion and made to act as a loop or pulley by 
suturing it into the pisiform ligamentous tissue, leaving its original inser- 
tion intact. 

Instead of constructing a pulley, one can pass the tendon used around 
the flexor carpi ulnaris tendon and on to its insertion in the phalanx of the 
thumb. The flexor carpi ulnaris then aids in the opposition. 

For the sake of clarity, a few concrete examples of the technique are 
shown in Figures 4-A through 4-F. 

In the reconstruction there may be available some tendons of the long 
extensors of the toes or opposite the palmaris longus. With a free graft 
of one of these, a pulley can be made at the pisiform bone. The tendon of 
the palmaris longus is detached at its insertion and prolonged by a free 
tendon graft, passed through the pulley and then subcutaneously across 
the thenar eminence over the head of the metacarpal to be inserted through 
a drill hole in the dorso-ulnar aspect of the base of the proximal phalanx. 
Another method is to detach the tendon of the extensor carpi radialis 
brevis high, draw it out at its insertion, and then pass it subcutaneously 
across the thenar eminence to the pisiform bone. Here it is passed through 
the pulley and then sutured to the distal end of the tendon of the flexor 
carpi ulnaris. The flexor carpi ulnaris muscle is quite strong, and, if it is 
used to give the thumb opposition, its normal function of ulnar palmar 
flexion is not lost. Also, if the extensor pollicis brevis is used, the function 
of extension of the thumb is not lost. 

CONCLUSION 

The opposable thumb is valuable to man. A thumb in true opposi- 
tion is not only opposite the fingers, but it is far forward from them and is 
rotated so that the pulp faces that of the fingers and the nail parallels 
the palm. Any tenoplasty to produce this must adhere to two essential 
principles. The tendon must pull subcutaneously in the right direction 
toward the pisiform bone and it must be inserted in the dorso-ulnar aspect 

the journal of bone and joint sorgeul 



OPPOSITION OF THE THUMB 


283 


of the base of the proximal phalanx of the thumb to give pronation. This 
may be accomplished by using any of various muscles for motor power, 
and for the tendon either the extensor pollicis brevis tendon or any one of 
various tendons prolonged by tendon grafts. The tendon used is made to 
pull in the right direction either by passing it through a tendon pulley 
constructed at the pisiform bone or by passing it around the tendon of the 
flexor carpi ulnaris. 


BIBLIOGRAPHY 

Ashley-Montagu, F. M.: Primate Thumb. Am. J. Phys. Anthropol., XV, 291, 1931. 

VON Baeybk: Bewegungslehre und Orthopadie. Ztschr. f. orthop. Chir., XL VI, 24, 1925. 

Baldwin, W. I. : Orthopaedic Surgery of the Hand and Wrist. In Orthopaedic Surgery 
of Injuries. Vol. I, p. 277. Edited by Sir Robert Jones. London, O.vford Uni- 
versity Press, 1921. 

Boechardt, M.: Schussverletzungen peripherer Nerven. Beitr. z. klin. Cliir., XCVII, 
233, 1915. 

Bunnell, Steeling: Reconstructive Surgerj' of the Hand. Surg. Gj'nec. Obstet., 
XXXIX, 259, 1924. 

Camitz, H. : liber die Beliandlung der Oppositionslahmung. Acta Chir. Scandinavica, 
LXV, 77, 1929. 

Cook, R. J. : Quoted by Taylor. 

Fobrster, O. : Die Symptomatologie und Therapie der Kriegsverletzungen der periph- 
eren Nerven. Deutsche Ztschr. f. Nervenheilk., LIX, 32, 1918. 

GRtiNKORN, J. : Die Daumenopposition, ihre muskelphysiologisclie Erklarung und die 
Behandlung des Oppositionsausfalls. Ztschr. f. orthop. Chir., LVII, 517, 1932. 

Huber, Eugen.: Hilfsoperation bei Medianusiahmung. Deutsches Arcli. f. klin. Med., 
CXXXVI, 271, 1921. 

Jahn, a.: Aktiver Ersatz bei Oppositionslahmung des Daumens. Ztschr. f. orthop. 
Chir., LI, 100, 1929. 

Koetzeborn, a.: Operative Behandlung der sogenannten Affenhand. Arch. f. klin. 
Chir., CXXXIII, 465, 1924. 

ILrukenberg, H.: Ueber Ersatz des M. opponens pollicis. Ztschr. f. orthop. Chir., 
XLII, 178, 1921-1922. 

Lange, Fritz: Die epidemische Kinderliihmung. In Lehmanns mcdizinischo lA;hr- 
bucher. XI. Bd. Munich, J. F. Lehmann, 1930. 

Lyle, H. H. M. : The Disabilities of the Hand and Their Physiological Treatment. 
Ann. Surg., LXXVIII, 810, 1923. 

Result of an Operation for Thenar Paralysis of the Thumb. (Extensor- 
Flexor-Flexor-Plast}’.) Ann. Surg., LXXIX, 933, 1924. 

Mauss, Theodor, und Kruger, Hugo: Beobachtungen und Erfahrungen bei Unter- 
suchungen und Opcrationcn von Schussverletzungen der periphorcn Nerven, mit 
bcsondcrer Bcriicksichtigung veralteter Falle und differcntialdiagnostisch in 
Bctracht kommender traumatischer Affektionen des Riickenmarks. Beitr. z. klin. 
Chir., CVHI, 143, 1917. 

Mayer, Leo: lA)op Operation for Paralysis of the Adductors of the Thumb. .-Vm. J. 
Surg., II, 456, 1927. 

Ney, K. W. : A Tendon Transplant for Intrinsic Hand Muscle Paraly.si.'. Surg. Gynec. 
Obstet., XXXIII, 342, 1921. 

Nicolaysen, Jou.xn: Transplantation des M. abductor dig. V. bei fchlcnder Oppo^itions- 
fiihigkcit des Daumens. Dcut.«che Ztschr. f. Chir., CLXVIII, 1.33, 1022. 

Nn.soN.VE, H.: Cher die Behandlung dcrOpponcnslrdimung des Daumens. .Acta Orthop. 
Scandinavica, I, 00, 1930. 

Pl.\it, Hauuy. and Bristow, W. R.: The Remote Results of Operations for Injuries- of 
the Periphend Nerves. British .1. Surg., XI, 535, 1923-1924. 

VOL. NX. NO. 2. APRIL IS-IS 



284 


STERLING BUNNELL 


Roeren, L. ; Quoted by Griinkom. 

Royle, N. D.: Operation for Thenar Paralysis. Med. J. Australia, II, 155, 1936. 

SiLFVERSKioLD, NiLs: Seluientransplantationsmethode bei Liihmung der Oppositions- 
fiihigkeit des Daumens. Acta Chir. Scandinavica, LXIV, 290, 1928. 

Spitzv, H.: Die krankliaften Veriinderungen der oberen Extremitiit. Verhandl. d. 
deutschen orthop. Gesellsch., XXV, 76, 1930. 

Steindler, Arthur: Ortliopedic Operations on the Hand. J. Am. Med. Assn., LXXI, 
1288, 1918. 

Die poliomj'elitischen Liihmungen der oberen Extremitiit. V.er- 
handl. d. deutschen orthop. Gesellsch., XXV, 113, 1930. 

Stiles, Sir H. J., and Forrester-Brown, M. F.: Treatment of Injuries of the Spinal 
Periplieral Nerves, p. 167. London, H. Frowde and Hodder & Stoughton, 1922. 

Strasser, Hans: Lelirbuch der Muskel- und Gelenkmechanik. Berlin, Julius Springer, 

^ 1908-1917. 

Taylor, R. T. : Reconstruction of the Hand. Surg. Gynec. Obstet., XXIXII, 237, 1921. 

Thole: Kriegsverletzungen peripherer Nerven. Beitr. z. klin. Cliir., XCVIII, 131, 
1915-1916. 

Troxell, E. L. : The Thumb of Man. Scient. Montlilj^ XLIII, 148, 1936. 

Weil, S. : Operative Behandlung der sogenannten Opponensliihmung. Klin. Wchnschr., 
V, 650, 1920. 

Whitchurch: Quoted by Griinkom. 


THE JOURNAL OF BONE 


.\ND JOINT SURGERY 



DISEASES OF THE APOPHYSEAL (INTERVERTEBRAL) 
ARTICULATIONS 


BY ALBERT OPPENHEIMER, iM.D., BEIRUT, SYRIA 
From the Department of Roentgenology, American University of Beirut 

This study has its origin in the commonplace observation that recur- 
rent or persistent pain and stiffness in the spine are not ahvays associated 
with demonstrable anatomical changes, and that well-marked spinal 
lesions may be found in the absence of any clinical sj’-mptoms. This 
discrepancy is not fully explained by the variable condition of the verte- 
bral bodies, intervertebral discs, and spinal ligaments, or by disturbances 
in the functional correlation between the muscles and bones of the back. 

Little is known in this connection about the behavior of the apo- 
physeal joints. There are investigations on the pathogenesis and morbid 
anatomy of certain inflammatory and degenerative diseases (Beneke; 
Burckhardt ; Eaton; Fischer and Vontz; Fraenkel ; Giintz; Klinge; Schmorl 
and Junghanns; Shore; Simmonds; and Siven); on their relations to s 5 ’-s- 
temic and traumatic affections of the spine (Beneke; Fraenkel; Knaggs; 
Lang; Lange; Schmorl and Junghanns; and H. Turner); on the roentgeno- 
graphic technique involved (Dittmar; Ghormley and Kirklin; Jordan; 
and Lange); and on the correlation of roentgenological and anatomical 
findings (Bakke; Forestier, Coliez, and Robert; Robert and Forestier; 
Schmorl and Junghanns); but .systematic studies on the interrelations 
between the clinical conditions and the underlying anatomical changes 
have not yet been published. 

Significant incipient and transitional phases are met with on autops}' 
only ver}-^ exceptionally; thus there is as 3 ’^et no uniformit 3 '^ in interpreta- 
tion of pathological findings in spondylarthritis. Clinicallj’’, affections of 
these articulations do not cau.se verj’" distinctive local manife.'itations. 
Roentgenologicallj’’, some of the pathological structures involved are 
too radiolucent to produce definite shadows; and the inaccessible 

position of the joints, their complicated structure, and their variable rela- 
tion to the vertebral bodies render the articulations almost invisible on 
“routine” roentgenograms. Thej’- are, however, demoiLstrable b 3 ' meth- 
ods more recenth’^ developed, but, since the elaborate technique involved 
has not 3 ’^et been generalh’’ adopted as a part of standard examinations of 
the spine, the observations arc still too limited in number to allow con- 
sistent interpretation. 

It is for these various reasons that the author’s own findings are here 
submitted. Thc 3 '’ are the result of 1,000 roentgcnograjihic examinations 
of the spine; of clinical and rocntgcnographic observations on 147 patients 
with various lesions of the apopin'.soal joints, main' of whom have been 
reexamined at intervals during periods of from one to three 3 'ears; and of 


VOI,. XX. XO. 2. .\rniL I93< 



286 


ALBERT OPPENHETMER 


studies on the differences between anatomical and roentgenological 
findings. Special attention has been given to the following questions: 

1. Can the diseases be classified anatomically or etiologically? 

2. Are there demonstrable interrelations between certain clinical 
and distinct anatomical findings? 

3. What are the relations between diseases of the apophyseal joints 
and affections of other elements of the spine? 

4. Can treatment be directed by the results of such diagnostic 
evaluation? 


ROENTGENOGRAPHIC ASPECT 

The apophyseal articulations are the only true joints of the spine. 
Considered both as units and as a system of interlinked joints, they are 
fairly well separated from the anterior Aveight-bearing section of the 
column which is formed by the “axial elements”, — that is, vertebral 
bodies, intervertebral discs, and longitudinal ligaments. Unlike the 
cancellous A^ertebral bodies, the articular processes, as parts of the arches, 
consist of compact bone. 



ANODE 



CERVI CAL 


Thorac ic 



film 


Fig. 1 

Positions for roentgenographic demonstration of the left apophyseal articulations. 
The arrows indicate the direction of the central ray. 


The superior and inferior articular processes are the parts of one bone 
which, having no anatomical designation, is here called “articular seg- 
ment”; its center, from which the articular processes originate, is the 
interarticular portion. Each articular process has a facet covered by 
cartilage; the joint space between them normally A'^aries in width and 
amount of synoAua.^® The anterior portion of the capsule forms the 
posterior border of the intervertebral foramen through AAdiich the cor- 
responding spinal nerves pass; its posterior part is covered by the liga- 
mentum fiavum. The other periarticular ligaments are of little impor- 
tance pathologically. 

The articular surfaces Amiy in position and shape in the seA^eral regions 
of the column. The relatiA^e positions of the patient, the tube, and the 

THE JOURNAL OF BONE AND JOINT SURGERA 



DISEASES OF THE APOPHYSEAL ARTICULATIONS 


287 


film are shown in Figure 1. The roentgenograiihic technique is discussed 
in a separate report. 

On physical examination in each case, the mobility of the spine was 
studied; also the type of pain possibly elicited by palpation and percus- 
sion, or by certain active and passive movements of the spine and limbs, 
especially backward stretching of the spine. A majority of patients had 
complete clinical and laboratory examinations in the hospital. A detailed 
history was obtained in all cases. 

PATHOLOGICAL CHANGES 

The apophyseal joints, being covered by thick layers of soft tissues, 
do not show, when diseased, such conspicuous signs as swelling or redness. 
The type of pain in the spine and its relation to posture and to certain 
movements may often give suggestions as to the underlying morbid condi- 
tion; but, since the diagnosis in most cases depends eventually upon the 
roentgenological findings, these are here taken as landmarks. The 
American terminology is followed in this report; “atrophic arthritis” 
corresponds to the British “rheumatoid”, to 
the German “primary” or “ Infekt-arthritis” , 
and to the French “arthrite"; “hypertrophic 
arthritis”, to “ osteo-arthritis”, to “Arthrosis" 
or “ Osteo-arthropathie” , and to “ arthrose” , re- 
spectively. 

These anatomical designations are here 
used because, being the simplest, they afford 
the most satisfactory basis for discussion, 
although obviously the purely anatomical 
view cannot take into account other aspects 
of the matter. 

Atrophic Spondylarthritis 

Atrophic arthritis, characterized by an 
inflammation affecting primarilj'- the sjmovial 
membranes, occurs in the apoph 3 ’’seal joints in 
one of two main tjqies, — namelj% acute or 
chronic. The acute form has been found to be 
a strictly localized condition; the chronic 
develops into a distinctlj’’ systemic disease in 
typical cases, but maj"^ in others become ar- 
rested and then remain more or less localized. 

Acute 

Seven cases have been observed, — two 
males and five females; the youngest patient was nineteen years of age and 
the oldest thirty-seven. 

Following an acute respiratory- infection, dull pain, confined to a 

VOI.. XX. NO. 2. . 



Fig. 2 


Acute spondyl.arfhritis. A 
defined soft sli.adow obscures 
the third cervical npophy.-eal 
joint space (arrow). No other 
changc.s are prc.-icnt. 

The patient wa.s a male, 
twenty-nine yeans old. He 
complained of pain in the 
neck, which nidiateil to the 
left elbow. 


.M’nii. mss 




288 


ALBERT OPPENHEIMER 


small section of the spine, developed 
“ over-night". In five cases, the cervical 
spine was affected; in two, the sacro- 
Jiunbar region. Pressure upon the re- 
gion involved elicited severe pain radi- 
ating into the arm or along the course of 
the sciatic nerve. A sensation of stiff- 
ness in the painful area was complained 
of. On examination, increased muscle 
tension in this area was evident, but the 
mobility of the spine was found free. 
No other joints were simultaneously 
affected. 

Roentgenologically, no changes 
were found in two instances. In three 
cases, a homogeneous hazy shadow, ex- 
tending slightly beyond the margins of 
the articular processes, obscured the 
apophyseal-joint space of the painful 
cervical articulation (Fig. 2). In one 
of these cases, both the bone structure 
and the outlines of the corresponding 
articular processes were Jiormal. In tlje 
two other patients, the outlines of the 
facets were indistinct and the bone 
density of the articular processes was 
moderately diminished (Fig. 3). In all 
the cases, the discs and the vertebral 
bodies were normal. The shadow described corresponds in location and 
in size to the articular capsule; it is too small and too circumscribed to 
represent, for example, a thickened muscle. Its disappearance with sub- 
siding clinical symptoms characterizes it as the expression of a transient 
swelling. 

Two patients left the hospital before treatment was attempted. In 
two other cases, the symptoms subsided entirely within ten days under 
short-wave treatment over the diseased region. In the fifth case, there 
was a recurrence after seven weeks. Reexamination revealed chronic 
tonsillitis with pus in the very large tonsils. Following tonsillectomy, the 
symptoms subsided and have not recurred (seven months after operation). 

In the sixth case, severe pain in the lower back associated with ex- 
cruciating "sciatica", loss of reflexes, and muscle atrophy in the diseased 
leg had persisted for eleven months. In this patient, mottled demineral- 
ization of the left sacrolumbar articular processes and blurred outlines of 
the facets were found,®"* but the joint space itself was of normal width. 
Within forty-eight hours after removal of the inflamed tonsils, this patient 
was completely cured; at present, nineteen months after tonsillectomy, 

THE JOUnXAL OF nOXE AXD JOINT SUnGEIlY 



Fig. 3 


Acute spondylarthritis. The 
fourth and fifth cervical apophyseal 
joint spaces are obscured (black ar- 
rows), and there is slight generalized 
rarefaction of the corresponding ar- 
ticular processes (white arrows). 
Compare with the normal upper 
joint space and bones. 

The patient, a female, aged 
twenty-eight years, had a low-grade 
fever, severe pain in the neck with 
marked rigidity caused by muscle 
tension, and severe pain in the right 
arm with complete disability. 



DISEASES OF THE APOPHYSEAL ARTICULATIOXS 


289 


he is in perfect health, but the articular processes involved are still a little 
less dense than on the normal side. In the long duration of the disease, as 
well as in the marked involvement of bony parts, this case differs in degree 
from those preceding it. 

The condition here discussed is marked by a localized, usually 
monarticular inflammation in an apoph 3 ^seal joint. The normal width 
of the articular spaces indicates that the cartilages remain intact. Ac- 
cordingly, restoration to normal is still possible. The articular affection 
was associated with acute respiratory infection and, in two cases of 
longer duration, with chronic tonsillitis. A causative correlation with this 
focal infection was made very probable by the immediate and lasting 
result of tonsillectomy. 

None of the patients had symptoms of rheumatic fever; the presence 
of definite anatomical alterations in the absence of noticeable general 
symptoms stands in contrast to this polyarticular affection. Nevertheless, 
rheumatic fever and acute phases of atrophic arthritis may “differ in de- 
gree rather than in kind”.^® The condition is best termed “acute 
spondylarthritis” (spond?/Zos= vertebra; arZ7iron= joint); since hyper- 
trophic arthritis is never acute, it would seem unnece.ssarj’- to add 
“atrophic”. 

Chronic 

Chronic atrophic arthritis is characterized by destruction of articular 
cartilages, — an irreparable lesion, for cartilage cannot be regenerated. 
Hence the distinction between acute and chronic atrophic spond 3 darthritis 
is here not based upon the duration of the clinical S3’’mptoms, but is 
determined by the absence, in the former, of destruction of cartilage. 



Fig. -J-A Fig. 4-B 

Chronic atropliic .spondylartlirilis. The .'p-icc between tlie left fiftli and sixtii 
cervical articular procc.-;.<cs is much narrower (arrow) tlian the richt. .•\niocbia‘-i^-. 
Case referred to in text. 


VOL. XX NO, 2, .\rnir. inns 



290 


ALBERT OPPENHEIMER 



Fig. 5 

Chronic atrophic spondyl- 
arthritis. The fifth thoracic 
apophyseal joint space is nar- 
rowed (arrow); the supei'ja- 
cent articular process is thin- 
ner and less clearly defined 
than in the lower normal 
joints. 

The patient, a female, 
aged thirty-two, complained 
of pain in the back, which ra- 
diated along the intercostal 
nerve. Rotation to the left 
was impaired, and rigidity of 
the thoracic spine was present. 
There was no fever. 


Roentgeiiologically, therefore, the differen- 
tiation is made according to the width (normal 
or diminished) of the involved joint space. It 
is obvious that destruction of cartilage nar- 
rows the joint space. 

At this stage (while still uncomplicated by- 
secondary changes to be discussed later) the 
disease is rarely observed. The author has 
seen four cases. 

A merchant, forty-two years of age, complained of 
severe pain in the left portion of the neck, followed after 
a week by stabbing sensations in the left shoulder, elbow, 
and hand, and numbness of the left finger tips. These 
symptoms had begun after a “chill” nine weeks previ- 
ously. Raising the left hand behind the neck caused 
pain in the neck and the shoulder. There were no other 
symptoms except low-grade fever. Clinically, there 
was very marked persistent tension of the extensors of 
the left side of the neck. The cervical spine was held 
stiff and straight; rotation was slightly impaired, and 
forward bending (both active and passive) was impos- 
sible. Percussion of the spinous processes did not elicit 
any sensation, but pressure upon the fifth and sixth 
cervical vertebrae, four centimeters to the left of the 
posterior mid-line, caused moderate pain locally and 
severe radiation into the left shoulder, with tingling in 
the finger tips. RoentgenographicaUj^, the space be- 
tween the left fifth and sixth cervical articular processes 
was narrowed as compared with the right side (Pigs. 4-A 
and 4-B). There was no demineralization of articular 
processes and no calcification of ligaments. The facets 
involved were parallel in position. Because endamoeba 
histolytica was found in the stools, antiamoebic treat- 
ment was given, with the result that the temperature 


became normal and spontaneous pain subsided within four days. Twelve days after 
the first examination, there was no longer any pain or muscle tension; nevertheless, the 
mid-cervical spine was rigid, and the involved joint space was as narrow as before. 


In two other patients with chronic tonsillitis, pain and rigidity of the 
section involved were found associated with narrowing of the cervical and 
lower thoracic articular spaces. No other joints were affected, and there 
were no “rheumatic” manifestations. In the fourth case, the thoracic 
articular processes adjacent to the narrowed joint spaces were .slightly 
rarefied (Fig. 5). This patient had chronic amoebiasis. 

The significance of these findings will be discussed together with those 
characteristic of ankylopoietic spondylarthritis. 


A n kylopoietic Spondijlarthriits 

This is a typical atrophic arthritis (as proved histologically 'h is, 42)^ 
with a marked tendency toward systemic involvement of all of the 
apophyseal articulations and demineralization of the vertcbial column. 

THE JOVUXAL OF BONE AND JOINT .SURGERY 



DISEASES OF THE APOPHYSEAL ARTICULATIONS 


291 


Eleven cases have been observed (nine males and two females). The 
symptoms varied in intensity according to the stage of the disease and to 
the extent of the involvement. The patients stated unanimously that 
pain in various regions of the spine had followed some acute infection. 
The spinal section involved had become stiff; pain and rigidity had e.x- 
tended gradually to other parts of the spine; and radiating pain into the 
extremities had accompanied these symptoms at irregular intervals. The 
clinical aspect is unmistakable: the region involved, and sometimes the 
whole spine, is perfectly rigid and at the same time straightened; the neck 
is fixed in a position of forward extension, and there is an angulation at the 
junction of the thoracic and cervical portions. Movements such as rota- 
tion or bending forward are performed by means of other joints, — the 
patient turns on his feet, and he bends forward by flexing at the hip joints, 
whereby the spine retains its rodlike straightness. Often the leg cannot 
be elevated unless bent at the knee joint as in sciatica (Lasegue’s sign), 
but without the sciatic pain. (See Figures 6-A, 6-B, 7-A, and 7-B.) 

Roentgenographically, in the early stages, the articular spaces af- 
fected are narrowed (Fig. 8-A); simultaneously, the articular processes 
appear demineralized. The facets remain parallel in position, and the 
section involved, losing its physiological curve, is straightened. Very 
soon (within from three to four months) the vertebral bodies also may 

decalcify, so that all the bone ele- 



ments of the diseased portion in- 
crease in radiolucence (Figs. 8-A and 
11-D). In the course of not less 



Fig. O-.-V. 


Fig. (FH 


Ankylopoictic .spondylartliritis ronfinpcl. at prc,<ciit, to tlie lumbar .•spine. 

Fig. (KA: Maximum degree of forward bending of whicli tlie {latient i*; eapable. 

Fig. G-Ii: To reach the floor with the finger tip-s, the patient I's obligeil to bend the 
knc&=. 

The patient, a niorchant, aged thirty-nine year?, gave a hisfory of jiain in the 
lower back of four yeans’ duration, mterinittent M-iatica, and gonorrhoea. M 
pre.'sent, there i.ss no pain, but rigidity of the lumbar region i.-s pre-ent. Then.' n no 
fever. I.asf'gue’s ^ign i> positive in the abssenee of any sciatic pain. 


VOL. XX. xo. e. 


Aritii. uns 



Case 3. Preoperative roentgenogram, with patient standing. 


THE JOURXAE OF BONE AND JOINT SURGERV 





DISEASES OF THE APOPHYSEAL ARTICULATIONS 


293 


apophyseal joints. This finding is the 
criterion of ankylopoietic spondylar- 
thritis. 

The vieiv here presented differs 
from that commonly expressed in the 
literature. The roentgenological find- 
ings upon which it is based, however, 
are consonant with early anatomical 
investigations (Fraenkel, Leri, Sim- 
monds, and Siven) that hai’^e recently 
been confirmed in every detail.*® It 
seems, therefore, that ankylopoietic 
spondylarthritis is a typical atrophic 
arthritis of the apophyseal joints. 

Secondary changes may occur .sub- 
sequent to this inflammation, although 
not of neces.sity always associated with 
it. These secondary changes consist in 
ossification of ligaments, especially of 
the ligamenta flava (Fig. 9) which his- 
tologically participate in the inflamma- 
tory proliferation of the synoidal mem- 
branes.'^' ’® Calcification of spinal lig- 
aments is a very common and totally 
uncharacteristic response to a great 
variety of vertebral lesions, — inflamma- 
tory, degenerative, destructive, or 
traumatic. The ossified longitudinal 
ligaments, when tangentially projected, 
the increased radiolucence of the bodies, 
and the rodlike ankylo.sis combine to 
give the appearance of a “bamboo 
spine”. The intervertebral spaces, 
with normal discs, rejiresent the nodes 
of the bamboo. The calcified ligaments 
appear stretched rather than tortuous 
as in diseases associated with thinning 
of the dises. Slight widening of the 
interverteliral spaces occurs occa.sion- 
allj% indicating that the discs, remaining normal, comjiress the rarefied 
vertebral bodies. 

Admirably described by the discoverers, Marie and Leri, the com- 
bination of .systemic bony ankylo.ris of the facets with ossification of the 
ligaments corresponds to the clinical entity, spoiidijlnsc r/iizninclir/ur. 
Because of the i'er 3 ’ marked degree of ligamentous calcification ciuir.ac- 
tcristic of advanced phases, some authors " regard this fli<(>.-i'C a- a 



Fig. 7-H 

Lumb.ar spine of patient shown in 
Fips. C-.A and O-B. Onh' oneapopliy- 
.'cal joint space i.s clearly distinpuisii- 
able (arrow); the other." are filled with 
bone substance. The lonpitudinal 
lipaments arc o.“.‘'ified. 


voi.. XX. -NO. a. . 


.M’llII. 193" 



«,bebt oppenheimek 



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^ ^ * FiffS* 3-1^^ 

Become “^antbo* 

a-s “■* n ^;;7oeun»t* e.^“'"!‘t"o“ ii-E so«e "r; 

s -.•»£ « ■"• “?l' -» - 


DISEASES OF THE APOPHYSEAL ARTICULATIONS 


295 



Fig. 9 

Oblique view corresponding to Fig. 
8-B. There is o.ssification of the liga- 
nienta flava (arrows). The lower two 
joint spaces are still visible, but narrow; 
their facets are ragged. The hazy 
shadow covering one intervertebral 
space (x) corresponds to the ossified 
longitudinal ligament shown in Fig. 

s-b; 






Fig. 10 

AnMopoictic spondylarthri- 
tis. The thoracic apophy.^cal 
joint spaces are narrowed and 
their facets are ragged (arrow i. 

The patient was a male, 
fifty-seven years old, with per- 
sistent herpes zoster and rigid- 
ity of the thoracic spine. 


observed, unless the condition is asso- 
ciated with some other changes of a dif- 
ferent nature. In a localized type of spondylosis o.ssificans. only the 
ligainenta flava calcify,- but even then the apophyseal articulations arc 
found intact (Fig. 12). 

In ankylopoictic spondylarthritis, o.ssification of the ligainenta flava 
usuallj' occurs during the period at which ankylosis becomes bony, as 
made evident by oblique dense lines at the posterior borders of the 
ankylosed joints. On the other hand, the longitudinal ligaments often 
calcify in a section of the spine distant from the seat of ankvlo-is. 


voi.. XX. xo. .^rnii. 





294 


ALBERT OPPENHEIMER 



Fig. 8-A Fig. 8-B 

Ankylopoietic spondylarthritis. Roentgenograms of lumbar spine. 

Fig. 8-A; The apophyseal joint spaces are still visible (arrows), but the articular 
processes are rarefied and the facets are ragged. 

Fig. S-B: Tiventy-nine months later. Ankylosis has taken place in all but one 
joint (arrows), and parts of the longitudinal ligaments have ossified (x). Note that 
the bone density of the vertebral bodies is less diminished than in Fig. 8-A, showing 
that rarefaction is more pronounced in the inflammator}’- stage than during the 
ankylosing phase. 

The patient, a female, aged thirty-one years, has had pain and stiffness of five 
years’ duration. 

Special “sj^'pclesmotic” type of chronic arthritis. Others -h have classi- 
fied spondylose rhizomelique as a form of spondylosis ossificans ligamentosa. 
The latter condition, however, is determined anatomically by systemic 
ossification of the ligaments in the absence of changes of discs and apo- 
physeal joints. Usually discovered accidentally in persons over fifty 
years of age during examinations of the chest, these changes are not asso- 
ciated with clinical symptoms. The posture is not altered (Fig. 11-A). 
Invariably, the apophyseal joints remain normal (Fig. 11-B). The tho- 
racic spine is commonly the seat of the most extensive calcification, and 
the more mobile cervical and lumbar sections are less involved, wherefore 
mobility is usually intact. Radiating pain in the exti'emities is never 


THE JOURNAL OF BO.VE AND JOI.VT SURGEHy 


DISEASES OF THE APOPHYSEAL ARTICULATIOXS 


297 



Fig. 11-C Fig. 11-D 


The intervertebral foramina may be reduced in width to Ie.?s than 
one-half of their original diameter (Fig. 13) by concentric calcifications.'"- 
At earlier stages, the swollen capsule also 


may compress the nerve roots. Whether 
or not such constriction will lead to actual 
compression of the nerves depends on the 
relation between the width of the foramina 
and the caliber of the nerves, for, as previ- 
ously mentioned,^-’ radiculitis is more 
common in diseases of the lower cervical 
and lower lumbar spine, where the thickest 
nerves pass through foramina not wider 
than those in the neighboring regions. 

Relations to other “rheumatic” af- 
fections have been reported, — for example, 
iritis'*^; and it is well known that arthritis 
of the costotransvcrsal joints'-', of the 
sacro-iliac articulations'", of the hips and 
.shoulders and of the hands or feet 
is sometimes superadded. Tlie saero- 
iliac joints were found affected within one 
j’car after the onset of spinal rigidity in ten 
out of eleven patients; the eostotran.sversal 
joints, in three cases more than five years 
after the condition of the spine had been 
discovered; and the hip joints, one knee. 



Fig. 12 

•SJK)ndylo^i< nssifio.'iiis licMiiicn- 
losa lorali'.ata (Hakkct. Only the 
licainenta flava are c)-"ifie<j' (ar- 
ixnvi. The aiviphy-etil joints are 
free. 


voi.. XX. NO. s. \rnii, ims 


296 


albert oppenheimer 


Fig. 11-A 


Fig. 11-B 


Difference between spondylosis ossifican.s ligamentosa (Figs. 11-A and 11-B) and 
spondylo&e rhizomelique (Figs. 11-C and 11-D). The patients have been photo- 
graphed in their accustomed posture. 

Figs. 11-A and 11-B: Spondylosis ossificans: normal posture; pronounced ossifica- 
tion of longitudinal ligaments (z) and normal apophyseal joints (arrows); normal 
vertebral bodies and intervertebral spaces. 

Figs. 11-C and 11-D; Spondylose rhizomelique: characteristic posture; spine stiff 
and flexion of thigh on diseased hip; apophyseal joint spaces ossified (arrows) and 
vertebral bodies greatly demineralized; ossified ligament (x); typical ankylopoietic 
spondylarthritis. 

This series shows how little the two diseases have in common. 


However, only when ankylosis of the most affected part is complete do all 
the ligaments, including the ligamenta interspinalia, ossify as a whole. If 
this '‘rideau osseux”^ (bony curtain) becomes very dense, the apophyseal 
articulations are overshadowed and no longer distinctly visible, but this is 
quite exceptional. It would seem evident, then, that spondylosis ossifi- 
cans ligamentosa is not to be confused with spondylarthritis ankylopoietica. 

In the latter condition, rigidity does not depend upon actual ankylosis 
of the facets, but is well marked as soon as cartilage is destroyed. This 
suggests that it is the inflammatory rather than the subsequent ankylosing 
process which leads to stiffness, as in atrophic arthritis. 

Quite commonly the whole of the spine is not involved equally and 
simultaneously; therefore, various phases of the disease overlap in the 
selfsame person befoi’e ankylosis is complete. The process may remain 
confined to one part of the spine for many years (Figs. 7-A and 14) or even 
for the entire lifetime, in which case demineralization seems less pro- 
nounced (Fig. 14). 




THE JOORXAI. OF BONE AXD JOINT .SUnOERV 


DISEASES OF THE APOPHYSEAL ARTICULATIONS 299 

because of pain in the neck and the shoulder girdle; but in the remaining 
eight patients, the condition was discovered accidentally, and no clinical 
s 3 Hnptoms were associated with it. In thirteen of the cases, endainoeba 
histolytica was found in the stools. 

Koentgenologicallj’', the thoracic siiine was found to be affected 
in seven cases, the lumbar spine in three, and the cervical spine in four. 
The articular processes were greatly increased in density; the facets were 
ragged; the apophyseal joint siiaces were irregularly narrowed; and there 
were thorn-shaped exostoses at the posterior borders of contiguous facets 
(Figs. 15-B, 15-C, and 15-D). These changes were confined to one 
articulation m five cases, and to two or three joints in three cases; while, 
in the others, the whole cendcal or thoracic spine was involved. The 
intervertebral spaces were normal, which shows that the discs were not 
affected; the vertebral bodies were intact; and there was no abnormalit 5 '' 


of posture. In three cases, parts of 
the anterior longitudinal ligaments 
were calcified. 

Hypertrophic Spondylarthritis in 
Abnormal Posture 

Eburnation and exostoses may 
develop wherever abnormal me- 
chanical stress persists after having 
caused damage to the cartilages or 
bones upon which it acts.'*’ ” In 
the spine, eburnation and exostoses 
develop in vertebral bodies, — for 
example, when abnormal contact 
between them or tension upon liga- 
ments is produced by thinning of the 
intervertebral discs, and in 

abnormal positions resulting from 
fractures, scoliosis and the like. 

Similarly, increased bone den- 
.“’ity and e.xostoses may develop in 
the articidar processes when the 
articular cartilage has thinned down 
as a consequence of persistent pres- 
sure upon it, — for example, when by 
thinning of the intervertebral discs 
(traumatic or degenerative) the 
subjacent (superior) articular proc- 
ess is displaced forward,^-’ or 
when deviation of the spinal a.xis in 
scolio.sis or fractures causes eom- 
I)ression (unilateral or circumscribed) 
of apo])hyseal cartilages.-' 

VOL. X.V. NO. 2. . 



Fig. 14 


.■\nkylopoictio .spondylarthritis arrc.<tcd 
and loc.alizod. There is bony ankylo.-i.s 
of one apopliyseal joint (arrow) and the 
adjacent joint .spaces are greatly nar- 
rowed. Thom-shaped prominenre.s at 
the margins of the vcrtchnd bodie,s are 
present, indicating partial o.s.^ification of 
their longitudinal lipiments. 

Tlic patient, a teacher, aged fifty-seven 
years, gave a history of pain and .sti(Tne.'s 
about twenty-five years prcrviously. The 
pain had sTibsided entirely after five years, 
but slight stiffness jwrsisted. Oidy the 
lumbar region was involveil. 


.\rniL i!>3s 




298 


ALBERT OPPENHEIMER 


and one foot, in one patient tliree 
years after ankylosis of the whole 
lumbar spine had taken place. On 
the other hand, in chronic atrophic 
arthritis involving, for example, the 
hands, the elbows, the knees, and the 
feet, the author has not been able to 
find similar changes in the column. 
The variable etiology of these diseases 
may play a part in determining the 
inconstancy of these interrelations. 

It would appear justifiable per- 
haps to consider the three types of 
atrophic spondylarthritis — acute, 
chronic, and ankylopoietic — as phases 
of a single continuum without assign- 
ing to any single one or to all of them 
a specific cause. The pathological 
findings described may be the ex- 
pression of reactions of these areas 
to stimuli of a number of kinds, but 
the reaction may stop at any point, 
or it may continue to the stage described as ankylopoietic spondylarthritis. 

H ypertrophic Spondylarthriiis 

Roentgenologically, hypertrophic arthritis is determined by in- 
creased bone formation within and around the articular surfaces. Hence 
the roentgenological determination differs of necessity from the anatomi- 
cal. The primary lesion is localized in the cartilage, and this obviously 
causes the narrowing of the joint space seen in the roentgenogram, — 
either uniform, as in destruction of the entire cartilaginous layer; or ir- 
regular, as in partial destruction. Both may be masked by articular 
effusion, which is common in the disease. 

Inflammatory osteoporosis (rarefaction) of the adjoining epiphyses, 
typical of atrophic arthritis, is not characteristic of the hypertrophic form. 
However, since hypertrophic arthritis is frequently the eventual outcome 
of some low-grade infectious (atrophic) arthritis, hypertrophic and 
atrophic changes may become superimposed. 

In the apophyseal articulations, the disease occurs in one of two inde- 
pendent forms, — primary, and consecutive to postural alterations. 

Primary Hyperti^phic Spondylarthritis 

Fourteen cases have been observed, — nine males and five females, all 
over fifty-three years of age. In three cases, the spine was examined 
because of herpes zoster that had persisted or recurred during four, seven, 
and eleven months respectively; in three others, examination was made 



Fig. 13 


Ank3'lopoietic spondylarthritis. Os- 
sification of all the ligaments. Con- 
striction of one intervertebral foramen 
by concentric ossification (arrow). The 
apophyseal joints are ankylosed and are 
not distinguishable. 


THE JOURNAL OF BONE AND JOINT SURGERY 






300 


ALBERT OPPENHEIMER 



Fig. 15-C Fig. 15-D 


Fig. 15-A: Normal lumber apophyseal joints. 

Figs. 16-B, 15-C, and 15-D: Three cases of primary hypertrophic spondylarthritis: 
joint spaces narrowed; facets ragged; articular processes greatly increased in den- 
sity and deformed by exostoses (arrows). Ankjdosis bj’’ fusion of exostoses in one 
lumbar joint in Fig. 15-B indicated by x. Intervertebral spaces and vertebral bod- 
ies normal. Three cases of chronic amoebiasis. 

Roentgenologieally, increased density and exostoses appear mainly 
at the tips of the displaced facets. In the lower lumbar articulations, 
increased density of the articular processes is normal, because the over- 
lapping of the cylindrical facets and the superimposition of the iliac bone 

THE JOURKAL OF DOXE AXO JOINT SURGERY 



DISEASES OF THE APOPHYSEAL ARTICULATIONS 


301 


produce, in the oblique view, a summation of bone shadows (Fig. 15-A). 
By the ragged outlines of the facets and the narrowing of the joint space, 
the abnormal joint can be distinguished from the normal joint (Figs. 15-B 
and 15-C). Pathological bone formations of contiguous facets may 
fuse.-®’ This results in a type of bony ankylosis distinguishable from 
that found in ankylopoietic spondylarthritis by the absence of general 
rarefaction and the presence of residual exostoses. The facets, in all 
these conditions, are not parallel in position, their displacement being one 
of the primary causes of the whole process. 

In the sixty-one cases observed, the clinical symptoms were those 
commonly found correlated with the condition underl 5 dng the displace- 
ment of the facets. Pain, localized or radiating, was the chief complaint. 
In most cases it was more iironounced during rest, especially in the small 

hours of the night when the pa- 



VOl., XX, XO. 2. APIIIL 1B3S 



302 


ALBERT OPPENHEIMER 



Fig. 17 

“Discogenetic” disease. Tlie in- 
tervertebral space is narrowed {x). 
There are no ciianges at the vertebral 
bodies, but upward displacement of 
the subjacent articular process (ar- 
row) has occurred, with narrowing of 
the apophyseal joint space and in- 
creased density of the articular 
processes. 


would be awakened by “rheumatic” 
pain in the shoulders, the arms, the 
lower back, or the neck. A sensation of 
stiffness, most marked in the early 
morning, commonly interferes tvith 
washing and dressing; in the course of 
the day both pain and stiffness become 
less acute. Rigidity was most pro- 
nounced in three cases, in which one 
articular process, impinging upon the 
adjacent vertebra,®'^* was surrounded 
by a broad area of intensively increased 
bone density (Figs. 15-C and 16-C). 

The inconstancy of the relations 
between hypertrophic spondylitis (a 
disease characterized by exostoses at the 
margins of the A’-ertebral bodies) and 
liypertrophic spondylarthritis has been 
repeatedly discussed.^*- In fact, 
changes in the apophyseal joints were 
evident in only 14 per cent, of our cases 
of hypertrophic spondylitis. This is 
not surprising, for the apophyseal joints 
differ in both structure and function 
from the intervertebral synchondroses 
that are foi'med by the discs and the 
adjacent vertebral surfaces. The vul- 
nerability of the articular cartilage 


is variable in different persons; therefore, mechanical stress does not of 
necessity lead in every instance to lesions of cartilage inducing arthritis. 
Hypertrophic spondylitis is very often the result of lesions of the discs; 
this was shown as early as 1824.'‘'-> On the other hand, thinning of the 
discs does not invariably lead to increased bone formation at the vertebral 
bodies (Figs. 16-A and 17). Similarly, the abnormal stress upon the 
facets in this condition does not of necessity induce lesions of cartilages. 
It would seem that both the vulnerability of the cartilage and the readi- 
ness of the bone to respond by formation of exostoses are important factors 

in the pathogenesis of these conditions. • i i 

This is shown by those instances in which no bone reactions develop 
at both the vertebral bodies and the articular processes, in spite of marked 
thinning of the discs, contact between the bodies, and pronounced thin- 
ning of the articular cartilages (Fig. 17). In these cases, none of the 
characteristics of hypertrophic arthritis become evident roentgenograph- 
icallv for only the intervertebral and the joint spaces seem to be affected, 
the bones are not involved. On the other hand, m thinning of the discs 
enormous exostoses at the corresponding vertebral bodies may be found 


tiik jouuxal of BO.N-K a.vd joi.vt .surgkrv 




DISEASES OF THE APOPHYSEAL ARTICULATIONS 


303 













... : 



. ■■ 









. X 2 






- / "• ; ' "■ 






.' 3 X 


Fig. 18-A Fig. 18-B 

“Discogenetic” h 3 ’'pertrophic spondj'litis of the upper lumbar spine. Antero- 
posterior and oblique views. There are large exostoses at the vertebral bodies 
adjacent to the narrowed intervertebral spaces (x), but no changes in the apophj-seal 
joints (arrows). 

in the absence of narrowing of the apophyseal joint spaces and of 
changes in the facets. This indicates that the vertebral bodies did re- 
spond to the abnormal mechanical stress produced by the thinning of the 
discs (Figs. 18-A and 18-B), but the cartilages resisted. 

Regardless of the presence or the absence of these secondary changes, 
thinning of the discs is the cause of their eventual development, for it leads 
to contact betw'een vertebral bodies, to abnormal tension upon ligaments, 
to displacement of articular processes, and to narrowing of the inter- 
vertebral foramina. The totality of these alterations has previously been 
referred to as “discogenetic disease”,’-- ” and for this reason the t3-pe of 
spondylarthritis that may develop in the course of the lesion is here desig- 
nated as the “discogenetic” form of h3’^pertrophic spond3iarthritis. 

Secondary Infection 

vSeventeen cases have been observed. In fourteen instances, tuliercu- 
losis of the vertebral bodies involved the articular processes; in three cases, 
an inflammation associated with condensation of the vcrteiiral liodies 
(h3-pertrophic spond3iitis) had spread to the articulations, as made evi- 
dent b3- increased densit3' of the articular processes. The joint spaces in- 
volved were found to be narrowed in ail these cases. Persistent jiain, 
imjiaired mobilit3-, and rigidit3' of the segment involved were the main 
clinical s3'mptoms. Tuberculosis, infection witii Iirucella’'", osteoiierio- 
stitis’’, and osteom3'elitis of vertebral bodies’’ have been rejiorted to 
involve the articular processes. This is a rare occurrence, — in onh- four- 
teen out of eight3--one cases of Pott’s di.-ea-e was definite evidence of 

VOI.. XX. NO. i>. . 





Fig. 19-A Fig. 19-B 

Pott’s disease. Collapse of lumbar vertebrae (x). 

Fig. 19-A: The articular pi-ocesses are not involved (arrow). 

Fig. 19-B; There is sliglit rarefaction of the articular processes of the diseased ver- 
tebra, with indistinct outlines of the facets and blurring of the corresponding joint 
spaces (arrows). 


articular involvement found. Even when the vertebral bodies have 
thinned down to a few millimeters in height, the articular processes may 
remain intact (Fig. 19-A). As long as the discs are not affected, they 
expand into the bones that have grown soft®®, thereby maintaining the 
normal distance between the articular processes and hence between the 
cartilages. Similarly, in systemic rarefaction inducing collapse of the 
vertebral bodies®®, or in vertebra plana (Cah'-e), the articular processes 



Fig. 20 

Platyspondylia aortosclerotica. 
There is flattening of the vertebral 
body (x), but no changes in the articu- 
lar proce.ss (arrow) are visible. 


are rarely involved (Fig. 20). Conse- 
quently, the clinical symptoms are 
commonly mild as compared with the 
IDi’onounced anatomical changes. One 
finds quite a number of patients with 
vertebrae destroyed by fractures, tu- 
mors, or infections, who have prac- 
tically none of the clinical symptoms 
typical of spinal lesions. 

Traumatic Lesions 

Fractures of articular processes 
are not very common; the author has 
seen four cases. Both the fracture 
line and the displacement are easily 
recognizable in roentgenograms taken 
in the oblique position, or in lateral 
views of the cervical .spine (Fig. 21). 
The callus formations, if any, are very 


THE JOURNAL OF BONE AND JOINT SUnOERY 


DISEASES OF THE APOPHYSEAD ARTICULATIOXS 


305 


small. Three patients, after a fall, had developed segmental neuritis, 
\\’ithout being conscious of a spinal lesion; the fourth had severe pain in 
the spine and marked rigidit}'-, but this -n'as probably due to a coexisting 
hypertrophic spondylarthritis. 

Isolated Rarefaction of Individual Articular Segments and Articular Processes 

Demineralization, irregular bone structure, and decrease in height of 
one articular process or of the two processes that form one articular seg- 
ment have been observed in eight cases in the absence of an 3 ^ demon- 
strable changes in the corresponding 
joint spaces, the vertebral bodies, and 
the discs (Fig. 22). In one case re- 
cently observed, the adjacent facet 
was found slightly deformed by 
exostoses surrounding the area op- 
posite the tip of the diseased articular 
process; in other instances, the super- 
jacent process seemed to impinge 
upon the softened bone.^‘ In six of 
the eight cases, the lesion affected the 
sixth inferior cervical articular proc- 
ess which, as previously reported is 
often normall}’’ smaller and thinner 
than the adjacent processes, and is 
particular!}’- liable to compre.ssion b}"- 
the superjacent and subjacent proc- 
esses during backward movements 
of the neck. 

The lesion is invariably asso- 
ciated with severe radiculitis. There 
is no rigidit}^ The etiologj^ is unknown; neither trauma nor malignanc}' 
has been involved. 

Tumors and Osteitis Fibrosa 

Destruction or cro.don of the articular processes ma}' be caused b\' 
various tumors (Fig. 23). In a case of Hodgkin’s disease tlie author has 
found infiltration of the thoracic articular processes, as confirmed b\’ 
autopsj^, to be associated nlth per.ristcnt herpes zoster. In one case of 
osteitis fibrosa the articular proce.^ses were involved, but the joint sj^aces 
were normal. There was no rigidit}’. 

Anomalies 

Congenital aplasia of articular jjrocesses is rare. Differences in size 
and shape are common. Lack of boin* union with the epiiihj'sis forming 
the tip of the process api)ears as a radioluccnt horizontal gaj) sometimes 
mistaken for a fracture line. Xone of these conditions is associated with 
clinical s\"mi)toms. 



Fig. 21 


Fracture of cen’ical articular process 
(arrow), the result of an accident t\yo 
years previously. Tliere is no pain in 
the spine, but the patient complains of 
tingling in the left finger tips. There is 
atrophy of the left interossei. 


voi. x.x, NO. 2. .\rnir, im' 




306 


ALBERT OPPENHEIMER 



Fig. 22 

Isolated rarefacition of one cer- 
vical articular process. The joint 
.spaces and vertebi-al bodies are 
normal. There is severe radic- 
ulitis with trophic lesions in the 
left hand. 



Fig. 23 


Neurofibroma. Note destruction of the 
articular processes. There is palsy of the 
right arm. 

Gaps in the interarticular portion 
(Fig. 24), tlie center of the articular seg- 
ment, are responsible for spondylolis- 
thesis; the clinical symptoms vary 
according to the degree of both anterior 
displacement and reactive changes.^® 


CLINICAL AND ANATOMICAL INTERRELATIONS 

When attempting to correlate the clinical with the underlying ana- 
tomical conditions, one is faced, at the outset, by the fact that anatomical 
lesions of the apophyseal articulations are not always associated with 
clinical symptoms. The significance of this statement, however, is 
limited by factors illustrated in the following case histories: 

Case 1. A. B., female, aged fifty-four years, a teacher, was first seen on November 
11, 1935. Roentgenographic examination of the genito-urinary tract revealed narrowing 
of the fourth lumbar and lumbosacral spaces and eburnation and marginal exostoses of 
the fourth and fifth lumbar vertebral bodies, with marked eburnation of their articular 
processes. The patient could not recall at any time having suffered from backache, 
lumbago, sciatica, or the like. The spine was freely moveable; there was no tenderness 
on pressure. 

At examination on May 15, 193G, tlie patient complained of severe lumbago witti 
bilateral sciatic radiation, and on April 12, 1937, she stated that she had been troubled by 
backache ever since the previous visit. Backward stretciiing, as when lifting an object 
from the floor, elicited pain in the back radiating down to the popliteal regions. The 
lumbosacral region was tender on pressure. The roentgenographic appearance of tlic 

Till-: jouhnal of honk and joint sunoEni 



DISEASES OF THE APOPHYSEAL ARTICULATIONS 


307 


lumbosacral spine was identical with that found 
seventeen months previouslj'. 

Case 2. A. S., male, fifty-three years -of 
age, a merchant, was seen on June 6, 1937, com- 
plaining of dull pain in the right shoulder and 
weakness of the right arm. The right deltoid 
muscle was much thinner than the left. The grip 
of the right hand was weak (the patient was right- 
handed). There was an area of diminished sen- 
sitivity to touch on the lateral part of the right 
forearm. 

Roentgenographic examination revealed 
narrowing of the fifth and sixth cervical inter- 
vertebral spaces and sublmxation forward of the 
sixth and seventh superior articular processes; 
exostoses on these processes bulged into the right 
fifth and sixth intervertebral foramina. The 
cervical spine was freely movable, and there was 
no tenderness on pressure or percussion. 

The patient stated that he had never suffered 
before from any kind of rheumatism; his wife, 
however, affirmed that “for at least twenty years 
past” the patient had very frequently com- 
plained of rheumatic pain in the shoulders, stiff- 
ness of the neck, and, more recentlj'-, of tingling 
sensations in the finger tips. This reminded the 
patient that he had consulted several physicians 
during the past ten years because of rheumatic 
pains, the nature of which, however, he was still 
unable to recall. (The patient is intelligent, calm, 
and highly spoken of as a very reliable person.) 

Case 3. A. J., female, forty-two years old, complained of pain in the right hand 
of eight years’ duration and recently associated with weakness of tlie grip. Twenty 
years previously the neck had often been painful and “stiff”. For the pa.st tliree weeks 
pain in the left shoulder radiating to the finger tips had considerably impaired the use of 
the left arm and hand. There was no tenderness or rigidity of any section of the column. 
During the past five years, every imaginable mode of treatment had been attempted 
without relief. The spine had never been e.xamined. 

Roentgenographic examination on June 16, 1937, showed that the fourth and fifth 
cervical apophyseal joints were almost ankylosed. Tlie discs were normal, but the liga- 
ments were calcified. 

These few examples out of many may serve to demonstrate tlie fol- 
lowing points: 

1. In the presence of definite anatomical changes, clinical symjitom.s 
may be temporarily absent, for the symptoms may develop a long time 
after anatomical changes have been accidentally discovered (('a.-^c I). 

2. The history is not reliable, “rheumatic” pains being subcon- 
sciouslj' minimized (Case 2). 

3. Clinical symjitoms may' fail to sugge.st a spinal le.<ion: conse- 
quently roentgenographic examination is often omitted (Case 3). Many 
cases thus escape statistical evaluation. 

4. In spite of marked and per.'^istent discomfort in the extremities, 

VOI.. X.X, KO. C. ArUIL UI.^S 



Fig. 24 


Gaps in interarticular portion are 
visible. No displacement is present 
in the upper joint, but there is slight 
forward displacement (incipient 
spondylolisthesis) of the superior ar- 
ticular proce.s? of the lower vertebra, 
causing widening of the gap. 

The patient was a female, twentj'- 
four years of age, who complained of 
pain in the lower back. 



308 


ALBERT OPPENHEIMER 


there may be no symptoms and signs referred to the spine (Cases 2 
and 3). 

5. Generally speaking, the roentgenographic appearance of apophys- 
eal lesions in vivo is clinically more significant than their aspect on 
autopsy. In anatomical investigations, the occurrence of narrowing of 
intervertebral foramina sufficiently marked to account for compression of 
nerves has been denied.^® This is easily explained by the fact that, on 
autopsy, dehydration of nerves and decongestion of inflamed tissues, as 
well as the absence of postural influences that lead by displacement of 
bones to narrowing of foramina in vivo, make the interrelations appear 
different from those roentgenographically recognizable in the living 
patient examined in the upright position. 

In this connection, however, it must be strongly emphasized that 
there neither is nor could possibly be a direct correlation between the 
degree and amount of the anatomical changes observed roentgenographic- 
ally and the severity of the clinical symptoms. It is in the incipient 
stages that pronounced pain and disability are common, while the roent- 
genographic signs are not very marked. On the other hand, extensive 
bone changes are, in general, merely the result of a chronic process; and 
immobilization by exostoses and ankylosis may prevent further irritation 
of the joints. 


DISCUSSION 

For the recognition and comprehension of the diseases of the apophys- 
eal articulations, it is necessary to consider them primarily and essentially 
as affections of true joints rather than as diseases of appendices of the 
vertebral bodies. That these joints are also parts of the spinal column is 
of secondary importance in this respect, for it has been the author’s 
experience that the interrelations between the different types of spondyl- 
arthritis and the various forms of spondylitis and spondylosis are much 
less definite and constant than has been believed. 

Roentgenologically, the two main types of arthritis reappear in 
affections of the apophyseal joints: atrophic spondylarthritis, marked by 
swelling of the capsule, rarefaction of bones, and, later, by destruction of 
cartilages; and hypertrophic spondylarthritis, in which hypertrophic bone 
changes are consequent upon lesions of the cartilage. As in all other 
localizations of arthritis, a combination of atrophic with hypertrophic 
changes may occur, — e. g., in low-grade infections. Another form develops 
when, for reasons not yet known, the articular bone does not respond to 
the injury resulting from loss of cartilage. Secondary involvement of the 
joints in diseases of the adjacent bones may occur just as in other articula- 
tions, but it is very noteworthy that affections of the vertebral bodies, 
both localized and systemic, involve the articulations only rarely. The 
compact bones of the pedicles seem less liable to infection and rarefaction 
than the spongy vertebral bodies, and the compensatory expansion of the 
intervertebral discs (if they are not affected by the disease), as well as the 


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DISEASES OF THE APOPHYSEAL ARTICULATIONS 


309 


considerable resistance of the articular cartilages to mechanical stress, 
protects the articulations from injury. The following observations suggest 
that hypertrophic spondylarthritis develops chiefly in those patients in 
whom the cartilages are especially vulnerable : 

1. There is a type of hypertrophic spondylarthritis in ivhich the 
cartilaginous lesion cannot be accounted for by abnormal mechanical 
stress; in thirteen of the fourteen patients in this group, endamoeba 
histolytica was found in the stools, and relief was obtained by antiamoebic 
treatment. In the Near East, from 12 to 28 per cent, of the population 
are infected with amoebae, but the vast majority of these patients have no 
signs of hypertrophic arthritis. 

2. Primary thinning of the intervertebral disc causes, by displace- 
ment of the superior articular process, very marked mechanical stress upon 
the facets. However, in only six out of 233 patients with thinning of the 
cervical discs and in forty-nine out of 204 patients with thinning of the 
lumbar discs were roentgenographic signs of hypertrophic arthritis found 
at this level. 

Clinically, the infectious origin of atrophic spondylarthritis and of the 
type of hypertrophic spondylarthritis mentioned is suggested by the co- 
existence with various infections, and by the cure or arrest obtained by 
treatment of the underlying disease. As in other localizations, atrophic 
and hypertrophic arthritis in the apophyseal joints differ, as a rule, in the 
clinical course: atrophic spondylarthritis is marked by a more continuous 
chronicity, while hypertrophic spondylarthritis is usually associated with 
acute exacerbations alternating with periods at which the .symptoms are 
very mild. Consequently, in hypertrophic spondylarthritis, one may 
find well-marked anatomical changes in patients who are free from dis- 
comfort during this examination, but, if one has an opportunity to re- 
examine these patients at intervals, symptoms of spondjdarthritis will be 
observed almo.st invarialilj’’ at some time or other. As in other joints, 
the inflammatory phase is marked by pain (spontaneous and on pressure) 
and by impaired mobility. Stiffness may be due to muscle tension, Init 
rigidity independent of muscle spasms has been found to be invariabi}' 
a.ssociated with narrowing of the apophyseal joint spaces indicative of 
thinning of the articular cartilage. This rigidity, unlike that caused by 
muscle tension, persists after the pain has stibsidcd. Rigiditj' is not al- 
waj’^s caused b 3 ’’ calcification of ligaments, or bj' tlie diminution of tlie 
distance between vertebral bodies that re.sults from thinning of tlie discs, 
or bj-- fusion of marginal vertebral exostoses. Even operative grafting 
of several vertebrae maj’’ have little influence upon tlie mobilitj' of the 
spine.® On the other hand, thinning of the articular cartilages of one 
single apophj'seal articulation ma 3 ' and docs produce rodlike rigidit 3 ' of a 
whole spinal section. 

The observations leave little doubt that the integrit 3 ' of the arlicuhir 
cartilages is e.ssential to the nonmal mobilit 3 - of the spine. This i< sub- 
stantiated In" the fact that inqiaired mobilit 3 'of the siiine !•; found onlv in a 

voi.. XX. xo. 2. .'^rnii. 



310 


ALBERT OPPENHEIMER 


certain number of patients with radiating pain in the limbs that has been 
shown to be produced mainly by primary thinning of the discs (Badgley; 
Hodges and Peck; Oppenheimer; and Williams). In these patients, there 
may be no pain in the spine itself, in spite of radiculitis causing severe 
trophic disturbances.''^ In only sixty-one of the 437 patients with “dis- 
cogenetic disease ” did the author find pain (spontaneous or on pressure) 
and a certain amount of rigidity of the affected section. In forty-nine of 
these there was definite narrowing of the apophyseal joint spaces at the 
level of the collapsed intervertebral space, with or without hypertrophic 
changes of the articular processes. 

On the other hand, radiculitis is by no means typical of discogenetic 
lesions; various diseases may, at least at certain stages, affect the inter- 
vertebral foramina.®-- This occurs, for example, by constriction of their 
lumen during proliferative inflammation in acute spondylarthritis, or in 
isolated rarefaction of articular processes. However, the present ob- 
servations reaffirm that pain in the spine itself usually precedes or accom- 
panies radicular symptoms when the disease originates in the apophyseal 
joints.®^ 

The classification of atrophic spondylarthritis is here given with some 
hesitation, but, because of the involvement of the synovial membranes and 
because of some demineralization in three of the cases, acute spondylar- 
thritis is grouped with the atrophic type. This classification is now 
generally accepted, but it may well be that in the future an etiological 
classification will be possible, in which some types of both atrophic and 
hypertrophic arthritis are considered to be of infectious origin. Such a 
division into infectious and non-inf ectious arthritis has already proved its 
clinical value.^® 


SUMMARY 

In answer to the four questions posed at the beginning of this paper, 
it seems justifiable to conclude as follows: 

1. The two main types of arthritis affect also the apophyseal joints. 
Atrophic spondylarthritis, associated chiefly mth focal or general infec- 
tion, occurs in an acute reparable form in which the cartilages are not in- 
volved; in a localized chronic type, marked by destruction of cartilage; 
and as a chronic, more or less systemic disease, ankylopoietic spondylar- 
thritis. Hypertrophic spondylarthritis, marked by destruction of carti- 
lage, but not necessarily by bone hypertrophy, is often the result of 
persistent changes in the position of the vertebrae; in another type, inde- 
pendent of mechanical factors, it is possibly of infectious origin (amoebi- 
asis) . Secondary involvement of the articular processes in inflammatory 
and rarefying diseases of the vertebral bodies is rare. Isolated rarefaction 
of the articular segments mthout cartilaginous lesions, another rare condi- 
tion, is etiologically obscure. 

2. Local pain (spontaneous and on pressure) and stiffness caused by 
muscle tension are found in active phases of any type of spondylarthritis. 


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DISEASES OF THE APOPHYSEAL ARTICULATIONS 


311 


Rigidity not caused by muscle spasms develops whenever articular carti- 
lages are affected. Rigidity without pain is observed in quiescent hyper- 
trophic and in arrested aiikylopoietic spondylarthritis. In diseases of the 
vertebral bodies and intervertebral discs, local pain and persistent rigidity 
occur chiefly when the apophyseal articulations are involved. Radiculitis, 
which may develop in any disease that affects the intervertebral foramina, 
is not characteristic of particular lesions. 

3. Atrophic spondylarthritis is independent of other systemic spinal 
diseases; there is especially no correlation either vdth spondylosis ossifi- 
cans ligamentosa or with the various types of spondylitis. Hypertrophic 
spondylarthritis, being intimately related to postural alterations (mainly 
those resulting from “ discogenetic ” lesions), is often associated mth 
traumatic changes, — hypertrophic spondylitis, scohosis, and the like. 

4. Acute atrophic spondylarthritis can be cured; chronic atrophic 
spondylarthritis can be arrested by successful treatment of the coexistent 
infection. In hypertrophic spondylarthritis, the treatment depends 
upon the underl 3 dag lesion (mechanical or infectious). 

BIBLIOGRAPHY 

1. Badglet, C. E.; Clinical and Roentgenological Study of Low Back Pain with 
Sciatic Radiation. A. Clinical Aspects. Am. J. Roentgenol., XXXVII, 454, 1937. 

2. Bakke, S. N.; Spondylosis ossificans ligamentosa localisata. Fortschr. a. d. 
Geb. d. Rontgenstrahlen, LIII, 411, 1936. 

3. Barr, J. S.: “Sciatica” Caused by Intervertebral-Disc Lesions. A Report of 
Forty Cases of Rupture of the Intervertebral Disc Occurring in tlie Low Lumbar 
Spine and Causing Pressure on the Cauda Equina. J. Bone and Joint Surg., XIX, 
323, Apr. 1937. 

4. Bekeke, Rudolf: Pathologisch-anatomische Grundanschauungen zur Lchre von 
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5. Brown, L. T.: The Conservative Treatment of Backache. J. Bone and Joint 
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6. Burckhardt, Hans: Die unspezifischen chronischen Erkrankungcn dor Wirbel- 
saule. Stuttgart, Ferdinand Enkc, 1932. 

7. Chaumet, G.: Traitc de radiodiagnostic. Squelctfe en general. Tete, rachis, 
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8. Cole, J. P.: Dislocation and Fracture-Dislocation of Lower Cervical Vertebrae. 
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9. Ditt.mar, Otto: Weitere Mitteilungen ilbcr Sclirugaufnahmcn von ICnochcn und 
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10. Eaton, E. R. : Chronic Arthritis. .4 Consideration of the Etiologic Factors. 
J. Am. Inst. Homcop., XXV, 379, 1932. 

11. Ely, L. W.: Inflammation in Bones and Joints, p. 3G5. PJiiladelphia, J. B. Lip- 
pincott Co., 1923. 

12. Fischer, Anton, und Voxtz, Oskar: Ivlinik der Spondylarthritis ankylopoetica. 
Mitt. a. d. Grenzgeb. d. Med. u. Cliir., XLII, oSG, 1930-1932. 

13. Forestier, j., Coliez, R., et Rorert, P.: Etude radiologique de pieces .seches de 
rhumatisme vertebral. Bull, et Mem. Soc. do Radiol. Med. de Franco, XXIII, 
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14. Fraenkel, Euges: Fbcr chronische ankylosiercnde Virbr-baulenver-'^toifung. 
Fortschr. a. d. Gob. d. Rontgcnstralilen, VH, 02, 1903. 


VOL. XX. XO. 2, APRIL I53S 



14 


F. L. BUTTE 


correction was obtained and has been maintained at tlie sites of the 
pseudarthroses in the previous area. The patient is normally active and 
has no symptoms referable to the spine. The shoulders are level, and the 
head and trunk are well centered over the pelvis. There is good flexi- 
bility in the unfused portions of the spine. 

Case 3 (Figures 9 and 10) 

S. B., female, aged thirteen years, had an “idiopathic” left thoraco- 
lumbar scoliosis, the primary curvature extending from the tenth thoracic 
to the fourth lumbar vertebra, with the apex at the first lumbar vertebra. 
Only the precorrective roentgenogram (Fig. 9) and the latest postoperative 
standing view (Fig. 10) are presented to show the unde.sirability of over- 
correction of a curvature and fusion in this overcorrected position. Fig- 
ure 10 was taken three and a half years after spine fusion from the tenth 
thoracic to the fourth lumbar vertebra. Note that the original left curve 
has been converted into a right curve, and that the end vertebrae, par- 
ticularly the fourth lumbar, are considerably overcorrected, — that is, they 
now tilt in a direction opposite to that in the original curve. To fuse a 
curve which has been overcorrected, or even a curve whose end vertebrae 
have been overcorrected, demands that the compensatory curves above 
and below the fused area not only straighten of their own muscle power, 
but actually reverse themselves to maintain good alignment. Overcorrec- 
tion of a curve or of its ends means for any individual case more correction 
than the compensatory curves can take care of, and will result in a lateral 
shift of the body opposite to that present originally. In this particular 
patient the thoracic compensatory curve (the fourth thoracic to the tenth 
thoracic) has straightened nearly completely after three and a half years 
and may eventually reverse itself, but one should not plan for such an 
eventuality in selecting the fusion area. A curvature should not be fused 
in an overcorrected position. 

Case 4 (Figures 11, 12, and IS) 

M. K., female, aged fifteen years, had an “idiopathic ” left thoracolum- 
bar scoliosis extending from the eighth thoracic to the fourth lumbar verte- 
bra, with the apex at the first lumbar (Fig. 11). There was a considerable 
shift of the trunk to the left with moderate prominence of the right hip. 
The curvature was corrected in the wedging jacket to the position shown 
in the spine-marker roentgenogram (Fig. 12). From the study of this 
roentgenogram, it was decided to make the rare exception of not fusing 
every vertebra in the primary curve, the so-called minimum area, but to 
leave out the eighth thoracic vertebra from the fusion. This was done 
because this end vertebra Avas overcorrected, — that is, its upper surface 
was tilted beyond a line transA''erse to the axis of the trunk (dotted line, 
Fig. 12). Therefore, in 1934, fusion Avas done from the ninth thoracic to 
the fourth lumbar A^ertebra. 

Figure 13 shows the end result three years later. The alignment is 


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DISEASES OF THE APOPHYSEAL ARTICULATIONS 


313 


3S. Robert, P., et Forestier, J.: Semeiologie radiologique des affections osteo- 
articulaires dites rhumatismales chroniques. J. de Radiol, et d’ElectroL, XX, 469, 
1936. 

39. ScHMORL, Georg, u^^) Junghanns, Herbert: Die gesunde und kranke Wirbelsiiule 
im Rontgenbild. Leipzig, Georg Thieme, 1932. 

40. Shore, L. R. : On Osteo-Arthritis in the Dorsal Intervertebral Joints. A Studj^ in 
Morbid Anatomy. British J. Surg., XXII, 833, 1934-1935. 

41. SiMMONDs, M.: tiber Spondylitis deformans und ankjdosierende Spondylitis. 
Fortschr. a. d. Geb. d. Rontgenstrahlen, VII, 51, 1903. 

42. Sirax, V. O. : Zur Kenntniss der sogen. chronisch ankylosierenden Entzundung der 
Wirbelsaule. Ztschr. f. klin. Med., XLIX, 343, 1903. 

43. Struxipell, Adolf: Ueber Muskelatrophie bei Gelenkleiden und tiber atrophische 
Muskelliihmungen nach Ablauf des acuten Gelenkrheumatismus. Mtinchener 
med. Wchnschr., XXXV, 211, 1S8S. 

44. Teschendorf, H. J.: Iritis rheumatica und Spondylarthritis ankj'lopoetica. 
Deutsche med. Wchnschr., LIX, 1576, 1933. 

45. Thojia, E.: Die Zwischenwirbellocher im Rontgenbild, ihre normale und patho- 
logische Anatomie. Ztschr. f. orthop. Chir., LV, 115, 1931. 

46. Turner, E. L., and OpPENHEiitER, A.: A Common Lesion of the Cervical Spine 
Responsible for Segmental X’euritis. Ann. Int. Med., X, 427, 1936. 

47. Turner, H.: Ueber die sogen. Versteifung der Wirbelsaule und tiber die 
Bechterew’sche und Strtimpell-Marie’sche Krankheit. Ztschr. f. orthop. Chir., 
XXXIV, 40S, 1914. 

48. UsiBER, F.: Zur Diagnostik und Therapie chronischer Gelenkerkrankungen. 
VeroflFentl. d. deutschen Gesellsch. f. Rheumabekampf., Heft 4, 144, 1929; Med. 
Welt, XVII, 593, 1929. 

49. Wenzel, Carl: Ueber die Ivrankheiten am Rtickgrathe. S. 89. Bamberg, W. L. 
Wiesche, 1824. 

50. Williams, P. C.: Lesions of the Lumbosacral Spine. Part II. Chronic Trau- 
matic (Postural) Destruction of the Lumbosacral Intervertebral Disc. J. Bone 
and Joint Surg., XIX, 691, July 1937. 


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ALBEKT OPPENHEIMER 


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37. PuTTi, V.: Sciatiche vertebral!. Riforma Med., XLV, 967, 1929. 

the journal of bone and joint surgery 



QUADRICEPS PARALYSIS 


315 


be successfully utilized as an extensor there would seem to be little doubt 
regarding the value of this procedure. 

“In those cases in which both groups of hamstring muscles are acting, 
the transference of the biceps with the tensors as described would proba- 
bly give the best obtainable results from tenolysis for paralysis of the 
quadriceps.” 

Since 1926, sixteen cases of quadriceps paralysis, in all of which 
knee-flexion and hip-flexion contractures were present, have been treated 
by operative transference of the iliotibial band. In eight of these cases 
the biceps muscle was also transplanted in conjunction with the iliotibial 
band. In earlier cases the iliotibial band was merely freed and sutured 
to the patella, and the biceps was transferred according to the methods 
previously described by Crego and Fischer. 

It seemed to the author that more radical dissection was necessary 
to utilize effectively the abundant muscle power available in that part 
of the gluteus maximus which is inserted into the fascia lata. It also 
seemed that the biceps muscle had not been sufficiently mobilized to place 
it in the position of strongest mechanical advantage for its new function. 
For these reasons the operative technique was gradually modified ex- 
tensively. Those of us who have observed these cases under the original 
technique and later with the modified method feel thoroughly convinced 
that the more radical procedure is amply justified by the improvement 
in function. 


OPERATIVE TECHNIQUE 

A long incision is made, beginning just below the greater trochanter 
and extending from the lateral aspect toward the middle of the dorsal 
surface of the thigh to the patella, and across the patella down through 
the tuberosity of the tibia. The edges of the skin are then reflected 
on each side by blunt dissection, fully exposing the fascia lata from the 
middle of the thigh to the inferior edge of the lateral surface. It is 
important that the reflection of the skin .should be sufficiently wide to 
e.xpose the insertion of the gluteus maximus into the fascia lata. The 
biceps tendon is next isolated just above the head of the fibula and, after 
two-thirds of this tendon has been stripped free from the head of the 
fibula, it is dissected upward until the muscle fibers of the short head 
begin to show. T.he dissection of the long head of the biceps only is then 
continued upward, either bluntly with gauze or by actually cutting it 
free from the short head. The long head of the biceps should be freed 
from surrounding structures .sufficienfl 3 ' high to enable its course to be 
changed, so that it will enter the tunnel which is later made for the two 
tendons at an advantageous angle. There is a distinct, lino of sejiaration 
between the short head and the long head, and it is possible to sejuirate 
them ea.'^ih’. There is no advant.age in tr^-ing to utilize the short head of 
the biceps, as it cannot be mobilized adequately without too much 
trauma, bleeding, and destruction of its own nerve .supj)l\': moreover, 

VOL. XX. xo. .<riiii. if.i.s 



AN OPERATION TO IMPROVE FUNCTION IN 
QUADRICEPS PARALYSIS * 

BY CARL C. YOUNT, M.D., PITTSBURGH, PENNSYLVANIA 

In 1926 the author read before the American Orthopaedic Association 
a paper on “The Role of Tensor Fasciae Femoris in Certain Deformities 
of the Lower Extremities”. In this paper emphasis was placed on the 
following facts: 

1. The so-called “hip-flexion contracture”, seen so frequently in 
untreated cases of anterior poliomyelitis, in most instances is not a true 
flexion contracture, but an abduction contracture, the structures chiefly 
involved being the tensor fasciae femoris, the portion of the gluteus 
maximus which is inserted into the fascia lata, and the pseudotendinous 
prolongation of these two structures, — that is, the iliotibial band. 

2. Because of the insertion of the iliotibial band into the tuberosity 
of the tibia, contraction results in external rotation of the tibia on the 
femur and is a factor in causing knee flexion, especially in those cases in 
which the quadriceps is weak or paralyzed. 

3. The biceps is an important contributory factor in the pseudo 
knock-knee, knee flexion, and rotation of the tibia in the presence of a 
paralyzed quadriceps. 

Cases were also reported in which the three deformities — hip flexion, 
knee flexion, and paralytic knock-knee — were successfully corrected by 
division of the iliotibial band and by the lengthening of the biceps tendon. 
One case was described in which the iliotibial band was transplanted to the 
patella to replace a paralyzed quadriceps. The following comments 
were made in regard to this case. 

“In those cases in which the quadriceps is paralyzed and the tensors 
of the fascia lata are active the advisability of utilizing the latter as ex- 
tensors of the knee suggests itself. Spitzy has devised and practised 
rather extensively an operation utilizing the tensor fasciae femoris muscle 
for this purpose. In his operation no consideration is given to the fact 
that a fair portion of the gluteus maximus functions as a tensor of the 
fascia lata and acts conjointly with the tensor fasciae femoris muscle 
by means of its fusion with the latter in the ilio-tibial band. With this 
in view the operation has been modified to the extent that instead of 
stripping free a narrow portion of the fascia lata, up to the muscular 
insertion of the tensor fasciae muscle, a broad fan-shaped section of the 
fascia lata is included, the broad part being taken from the lateral and 
posterior surface, the dissection extending up to the lower edge of that 
portion of the gluteus maximus which is inserted into the fascia lata. . . . 

If that portion of the gluteus maximus which acts as a tensor can thus 

* Read at the Annual Meeting of the American Orthopaedic Association, Washing- 
ton, D. a, May 10, 1933. 

314 


THE JOURNAL. OF BONE AND JOINT SURGERY 



QUADRICEPS PARALYSIS 


317 



Fig. 3 


upper third of the thigh. Where it approaches tlie insertion of the glu- 
teus maximus it is widened out considerably and stripped free up to the 
point where the fibers of the gluteus maximus insert into it. The mesial 
edge of the section of the fascia is stripped up, so that it includes the tensor 
fasciae femoris. 

Having freed the structures which are chiefly responsible for the 
contracture, it is found quite easy to correct the flexion and the rotation 
deformit}’’ at the hip and knee by manual force. It is advisable, however, 
lo use a moderate amount of force and not to attempt to overcome fully 
the contractures at this time. In the most extreme cases in the author’s 
series, not more than 20 degrees of hip flexion and 15 degrees of knee 
flexion have been present after the forced manipulation described. The 
final correction of these deformities should be deferred until after com- 
plete healing has taken place. 

In the earlier cases it was found that the transposed structures re- 
mained too far out on the lateral surface of tlie tliigh to give the maximum 
function. In order to transpose them to a position which would more 
ncarl}' approximate that of the quadriceps, a tube, constructed from tlie 
inner lip of the cut fascia lata, is made by folding it upon itself toward 
the mesial aspect of the limb (Fig. 1). In the upper part of tlie thigh 
tlie tube should be so placed that it will lie laterally and tlicn gradually 
extend obliquclj' toward the middle as it approaches a point about three 
inches above the patella. The transjjlant of tensor fasciae latac enters 
the tube at its toj), but it is necessary to make a sojiarate opening in the 
tube ai)]iroximately two inches below the toji for the biceps (Fig. 2). 
After emergence from the tunnel, the biceps is stitched to the fa-cial 

vot,. x.\, xo. .\run. I'.c.s 



316 


C. C. YOUNT 



Fig. 1 

Method of constructing tube: A, biceps; B, fascia lata and iliotibial 
band ; CC', line of skin incision. 


if it is retained as a flexor of the knee, it is unquestionably valuable in 
preventing the development of genu recurvatum, which of course is a 
possibility in these cases, especially if the other hamstring muscles are 
weak. The insertion of the iliotibial band is next freed subperiosteally 
from the tuberosity of the tibia. A strip about half an inch in width is 
dissected free, extending from the tuberosity laterally across the surface 
of the knee joint up to the part of the iliotibial band which is well defined. 
Beginning about two inches above the knee joint, the strip of the fascia 
lata which includes the iliotibial band is widened gradually toward the 



Fig. 2 

The fascial transplant traverses the tube made by folding the fascia 
lata A to A'. The biceps enters the tunnel at B. 

THE JOUnXAL OF BONE AND JOINT SUHGEIIY 



QUADRICEPS PARALYSIS 


319 


COMMENT 

This operation, of course, has been developed as a type of procedure 
to be used in a particular group of cases in which a fairly uniform type 
of deformity and similar residual power in the extremity are present. 
For that reason no attempt will be made to contrast it with other types 
of operations in which other muscles are utilized. It is the author’s 
belief that there is no best operative procedure for the replacement of the 
paralyzed quadriceps, but each case presents its own problem and the 
type of operation to be chosen wall depend upon the available muscle 
power for transference. 


REFERENCES 

Cbego, C. H., Jh., and Fischer, F. J.; Transplantation of the Biceps Femoris for the 
Relief of Quadriceps Femoris Paralysis in Residual Poliomyelitis. J. Bone and 
Joint Surg., XIII, 515, July 1931. 

Yount, C. C.: The Role of the Tensor Fasciae Femoris in Certain Deformities of the 
Lower Extremities. J. Bone and Joint Surg., VIII, 171, Jan. 1926. 


'■OU XX. NO. C. .KPUIL IfJi! 



318 


C. C. YOUNT 


transplant, as it will be 
found in most cases that 
the biceps will not reach 
the patella. Both these 
structures are then su- 
tured to the quadriceps 
tendon, after the latter 
has been incised in the 
mid-line one and one-half 
inches above the patella. 
The fascial transplant is 
divided into two parts at 
the end, and is imbedded 
in two holes (punched or 
drilled) in the patella. 
(See Figures 3 and 4.) 

After the usual clo- 
sure of the wound, a cast, 
extending from the peri- 
neum to the toes, is ap- 
plied. Moderate force 
only should be used in 
correcting knee flexion. 
In applying the cast the 
correction of knee rota- 
tion should not be over- 
Fig. 4 looked. A strict Soutter 

Showing the plastic suturing completed. position is not used im- 

mediately after the opera- 
tion, but gradual correction of the hip flexion is accomplished by elevating 
the buttock by means of boards and pillows under the mattress. 

POSTOPERATIVE CARE 

In cases with marked hip-flexion contracture, correction is deferred 
until approximately four weeks after operation, when the patient is 
placed in the strict Soutter position. Additional correction of the knee 
flexion is accomplished after the four weeks' period by means of a wedged 
cast. 

At the end of the fifth week after the operation, massage and muscle 
reeducation are begun. In most cases old braces which these patients 
have been wearing are refitted and worn usually only for six or eight 
weeks. Most of the author's patients have been able to walk without 
braces so soon after the operation that he has not felt it justifiable to 
order braces. The only adA^antage of the brace is that if it is worn the 
patient can be discharged from the hospital more quickly. 

THE JOURNAL OF BONE AND JOINT SURGERY 




5 




“SPONDYLODESIS” 


The Use of the Short Bone Graft in Fusion of the Tuberculous 

Spine 


BY J. DE MOL VAN OTTERLOO, M.D., ’S-GRAVENHAGE, NETHERLANDS 
From the Queen Sophia Memorial Children’s Hospital 


Tuberculosis of the spine is a condition which may give rise to difficul- 
ties in treatment, not only from the general pathological, but also from 
the orthopaedic point of view. It is the author’s purpose to discuss the 
causes of these difficulties and to advocate a method of treatment which 
has been found to improve the end results in many cases. 

The spinal tuberculosis of children should be considered separately 
from that of adults, because, as a rule, the course is different. 

In children spondylitis often leads to bony union of the involved 



Fig. 1 


Showing the tenth, elev- 
entli, and twelfth thoracic 
vertebrae and the first and 
second lumbar vertebrae. 
In the twelfth thoracic ver- 
tebra the upper articula- 
tions are in the frontal 
plane, while the lower ar- 
ticulations have turned 
about 90 degrees and are 
placed in the sagittal plane. 


vertebrae, while in adults the bony remnants 
of the vertebrae do not grow into one bone block 
and a pseudarthrosis remains as a result of the 
healing. Also, in the process of healing, the 
thoracic vertebrae behave differently from the 
lumbar vertebrae, due to the difference in ana- 
tomical structure. (See Figure 1.) When de- 
struction of the body occurs in the thoracic 
spine, the upper thoracic vertebra tips forward, 
being caught on the superior articular processes 
of the thoracic vertebra below; whereas, in the 
lumbar spine, the upper lumbar vertebra may 
sink down more perpendicularly upon the lower 
vertebra, because the surfaces of the lumbar in- 
tervertebral articulations are able to slide 
vertically along each other, as they are placed in 
the sagittal plane. Consequently, in the lum- 
bar column, there is a firmer contact between 
the fragments of the involved vertebrae, as the 
centra are vertical. 

In children a spondylitis of two or three 
lumbar vertebrae usually leads to bony union 
with or Avithout minimal kyphosis; whereas in 
cases of invohmment of the thoracic vertebrae 
frequently bony union does not occur and a 
kyphosis is unavoidable. In adults, hoAvever, 
neither thoracic nor lumbar spondylitis results 
in bony union, and a pseudarthrosis persists. 

It should not be forgotten that, in the 


320 


THE JOURNAL OF BONE AND JOINT SURGERV 



SPONDYLODESIS 


321 


n 


>> 


course of the disease, bony union of the small intervertebral joints may 
occur, although one often finds, in studying specimens of a tuberculous 
spondylitis, non-union of both vertebral bodies and intervertebral joints. 

As a matter of fact, in many cases in children, even after a long con- 
servative treatment, there results a non-union, — a pseudarthrosis of the 
involved part of the vertebral column. The motion and flexibility of this 
pseudarthrosis may be considerable. Roentgenographic examination in 
such cases may give an idea of this condition. 

To determine this pseudarthrosis, the examination is carried out as 
follows: The exposure is made with the patient in the lateral position and 
the spine in hyperflexion; then a second lateral exposure is made with the 
spine in hyperextension. When these roentgenograms are compared, the 
angle of inflexion — at the kypho.s — will show in many cases a change of 
20 degrees or more. This motion is in a most vulnerable place — a weak- 


ened area of the spine — which is con- 
tinuously exposed to distortion, bleed- 
ing, and oedema, and eventually may 
be complicated by neurological symp- 
toms. No doubt, many cases of re- 
currence of the tuberculous disease, as 
well as of back symptoms, are due to 
a more or less loose pseudarthrosis. 
To date, roentgenographic examina- 
tion of all patients seen by the author 
because of recurrence of symptoms 
showed a lack of bone-block formation. 

This condition may be compared 
with any pseudarthrosis resulting 
from tuberculosis, — for example, that 
of the hip. As the extrafocal fusion 
of a pseudarthrosis of the hip is con- 
sidered to be the best treatment, it 
seems advisable to base the treatment 
of a like condition in the spine on the 
same principle, — namely, an extra- 
focal fusion of the involved vertebrae. 

Jacques Calve, of Berck, France, 
was the first to advocate the use of a 
short bone graft which fuses onlj’- the 
affected vertebrae, and the author be- 
lieves that this is the correct jjroce- 
durc. If, after consistent conserva- 
tive treatment, the bonj' fragments of 
the involved centra do not grow into 
one bone block, and a pseudarthro.sis 
persists, a fusion of these vertebrae 

VOL. x.x. N-o. Arnii. 



Showing the natural phy.=iop.ifho!oKi- 
cal course of a of tuberculo-^is of Ifio 
spine (n, b, and c) with tlie formation of 
a coniix?n.satory lonio'i’i (c). Tlie long 
i)onc graft impedes; botli the collap'o 
(r{) and the formation of a Inrdo‘;is U‘. 
The .spondylodcs-is (/ 1 fu'Cs only the in- 
volved vertebrae. {Cotirirry of Sr'lrr- 
hnrisch Tijdfd.rift twr Ccnfffhindr.) 


mm mm 



322 


J. DE MOL VAN OTTERLOO 


should be done. The author proposes calling this operation “spondylo- 
desis”, because of the analogy to arthrodesis for the fusion of a joint. 

In the writer’s opinion, the long bone graft, extending from two 
vertebrae above to two vertebrae below the focus, is based on a false 
principle. Since the long bone graft fixes together a number of vertebrae, 
it interferes with the natural correction of the parafocal spine, — the 

forming of a compensatory lordosis (Fig. 2,c). 
Furthermore, this fusion, which is usually done in 
the early stage of the disease, is objectionable for 
the following reasons: It cannot arrest the exten- 
sion of the tuberculous disease, and it interferes 
with the process of repair, since it impedes the 
natural physiopathological collapse and the elimi- 
nation of space between the destroyed vertebrae. 
Also, is not the contraction of the fibrous tissue, 
which results from tuberculous granulation, a 
conditio sine qua non for a thorough repair of any 
tuberculous focus? 

The use of the long bone graft is supposed to 
be advantageous, because it protects against the 
intrafocal pressure caused by the weight of the 
upper vertebral column, but jDressure should not 
be feared during the stage of repair in which the 
spondylodesis is preferably done. It is even de- 
sirable as a functional stimulus to bone formation ! 

With the long bone graft, it is more possible 
to avoid motion between the involved vertebrae 



Fig. 3 



Fig. 4 Fig. 5 

Fie 3 and Fig. 4: Patient with tuberculosis of the second, third, and fourth lum- 
bar vertebrae, in whom total fusion of the lumbar spine bj^ a long bone graft had 
been performed. 

Fig. 5 : Same patient as shown in Figs. 3 and 4, after removal of the superfluous 
portion of the graft. 

THE journal of BONE AND JOINT SORGER'i 



SPONDYLODESIS 


323 


it 


jr 



Fig. 0 


Schematic drawings of the spines of eight cliildren. The curve licsido each 
sketch shows the increase in body weight a year before the operation and after tlic 
operation. (Cotirlcsrj of N cdcrlandsch Tijaschrifl voor Gcticc.d.-undc.) 

than with the short bone graft, but motion of the vertebrae, grown to one 
functional unit after the spondj'lodesis, should not be con.«idcred a.*; harm- 
ful, for the movements take place in the normal intervertebral disc.s and 
joints above and below this unit. 

Figures 3 and 4 show a boy sufTering from fuberculo.<i.s of the second, 
third, and fourth lumbar vertebrae. On admittance to the Hospital, the 
back was quite rigid and did not permit the patient to lean forward very 


VOL, XX. xo. :. APniL mss 




324 


J. DE MOL VAN OTTERLOO 


much, because of the total fusion of the lumbar spine by a long bone graft. 
Figure 5 shows the same boy after the superfluous part of the long graft 
had been removed. 

The short bone graft is based on a different principle; it is employed 
as a final procedure of conservative treatment. 

Every case of tuberculosis of the spine, in children as well as in adults, 
should be treated conservatively at first. The usual general treatment 
should be combined with absolute recumbency in a plaster bed for several 
years. The final spondylode.sis, which is done in certain cases, is only to 
be considered as a safety-lock to reenforce a healed condition. After the 
operation, the patient remains in a plaster bed for about six months and is 
gradually mobilized in a light, reenforced, celluloid jacket. As a matter of 
fact, the spondylodesis not only influences the local part of the spine, but 
it even improves the general condition. 

Figure 6 shows the spines of the first eight children operated upon 
by the author. The curve beside each of the schematic drawings shows 
the increase in body weight a year before the operation and a year after the 
oiDeration; the initial drop following the operative procedure is not re- 
corded. With the exception of the first and third cases, there is a remark- 
ably rapid increase in weight after the operation. 

These absolutely objective observations are very important, and the 
early results of the operation warrant its further use. 


THE JOURNAL OF BONE AND JOINT SURGERY 



ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


A Cause of Low-Back Pain with Sciatic Radiation * 

BY HOWARD A. BROWN, M.D., SAN FRANCISCO, CALIFORNIA 
From the Department of Surgery, University of California Medical School 

Enlargement of the ligamentum flavum producing compression of 
nerve roots is a more common cause of low-back pain with sciatic radiation 
than has been recognized. During the past seven months, seven patients 
with such symptoms have been proved at operation to have enlargement 
of the ligamentum flavum. Relief followed operation. 

Few reports of this condition have appeared in the literature and 
little attention has been accorded them. The earliest report which the 
writer has been able to find is that by Elsberg in 1913. This was a typical 
case of compression of the nerve root following trauma. An enlargement 
of the ligamentum flavum was found at operation and complete relief of 
.symptoms followed its removal. In 1916, the same author mentioned 
briefly two cases of enlarged ligamentum flavum. In 1931, Towne and 
Reichert reported two cases without antecedent trauma. An article by 
Puusepp appeared in the Esthonian literature in 1932, reporting three 
cases, in two of which trauma might have been a factor. In 1936, Ab- 
bott reported one traumatic case with recovery after operation. In the 
same year, Hampton and Robinson mentioned a case in an article on the 
roentgenographic findings in rupture of the intervertebral disc. Spurling, 
Mayfield, and Rogers have recently reported seven similar cases with 
relief of symptoms following operation. 

During the past few years we have learned that rupture and disloca- 
tion of a portion of an intervertebral disc is a rather common cause of low- 
back pain with sciatic radiation. The history and sjmiptoms of patients 
with enlarged ligamenta flava are e.s.sentially the same, and clinical 
differentiation between these two conditions is e.xtremely difficult or im- 
possible. In many instances, too, these syndromes cannot be differen- 
tiated clinically from lumbosacral or .«acro-iliac disorders, and careful 
study is required before a diagno.'-'is can be reached. 

A history of trauma, usually of relatively slight degree, is common. 
This was true in six of our seven patients. The most frequent history of 
injurj^ was of lifting, in a.ssociation with flexion and torsion of the spine, 
or a fall on the buttocks. The patient usually de.«cribcd a snapping 
sensation in the spine followed by pain low in the back and, later, gradtial 
radiation of the pain over the sciatic distribution into the thigh, the leg, 
and the foot. The interval between tlie onset of pain in the back and 
radiation into the leg varied from a few hours to several months. The 

• Received for publication, .September 27, 10.37. 

VOI., XX. XO. 2. .\rilll. I03S .‘{g.r. 



326 


H. A. BROWN 



Fig. 1 

Sagittal section of the lumbosacral spine. This drawing was made from a speci- 
men with an enlarged ligamentum flavum to show the mechanism of compression 
of the nerve root. The dura has been removed. 

A: Lateral view. 

B: The specimen has been rotated to demonstrate the point of compression of the 
nerve root. 

pain was usually severe and often disabling. In patients with enlarge- 
ment of the ligamentum flavum, sensory disturbances — numbness and 
paraesthesia — may be present, and there is likely to be some degree of 
motor weakness in the involved extremity. In a small percentage the 
sphincters may be affected. The symptoms are usually unilateral, but 
may be bilateral if the encroachment on the spinal canal is of sufficient 
extent. Weight-bearing almost always aggravates the symptoms, and 
rest in a recumbent position may afford some degree of relief. 

Objectively, the most common findings in our patients were some 
degree of scoliosis with a list to the unaffected side, a general restriction of 
movements of the back, and limitation of straight-leg raising on the in- 
volved side. Local tenderness over the lumbar spine was present, but 


THE JOURNAL OF BONE AND JOINT SURGERY 





ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


327 


was seldom severe. Some motor weakness was usually found, most often 
in the anterior tibial muscles. The most constant single finding was a 
decrease in the Achilles-tendon reflex on the side of the lesion. Sensory 
disturbances of varying degree were present over the buttocks, the pos- 
terior aspect of the thigh, the calf, and the foot. The most common 
sensory alteration appeared over the outer aspect of the lower part of the 
leg and the dorsum of the foot. 

Plain roentgenograms of the spine showed no pathological change in 
the bones or the joints and were 
of little value. 

A positive diagnosis of enlarge- 
ment of the ligamentum flavum can 
seldom be made from a clinical study 
alone. Spinal puncture and the use 
of lipiodol are required. An increase 
in the total protein content of the 
spinal fluid above fifty milligrams per 
100 cubic centimeters, suggestive of 
an intraspinal pathological process, 
was present in three of the four cases 
in which this determination was made. 

The Wassermann reactions were nega- 
tive in all seven cases. At least four 
cubic centimeters of lipiodol should 
be used in order to locate a minor 
defect in the spinal canal. Roent- 
genographic examination should be 
made with the patient in the prone 
position and any defects should be 
checked by immediate films, without moving the patient. In the ab- 
sence of abnormalities, the examination should be repeated after an inter- 
val of two weeks, to be certain that a defect lias not been overlooked. 

The enlargement of the ligaments occurred between the fourth and 
fifth lumbar vertebrae in si.x of our patients and at the lumbo.^acral 
junction in one. 

Study of the anatomj’’ of the ligamenta flava .show.? that even a mod- 
erate enlargement may cause compression of the nerve roots. Tliese 
ligaments arise from the dorsal and upper margins of each lamina, p.ass 
upward beneath the lamina immediately above, and enter the neural 
canal. They fuse in the mid-line and laterally have expansions which 
extend well down toward the anterolateral aspects of the neural canal 
and form the posterior margins of the intervertebral foramina. The 
ligaments lie in close association with the articular facets in the neural 
canal and, to some degree, form a capsular covering for the articulations. 
Directly below each ligament lies the intervertebral disc, and the very 
narrow space between them serves as a i)as'age for the nerve root after it 



Fro. 2 

Drawing made at operation after 
removal of the lamina. 

I; View before removal of the liga- 
mentum flavum: a, laminal margin; h, 
dural sac; c, enlarged ligamentum 
flavum intact. 

II; View after removal of the dorsal 
portion of the ligament: a, laminal 
margin; h, dural sac; c, unilateral en- 
largement of the ligamentum flavum. 


von. XX, NO. 2. ACnil. 193S 




328 


H, A. BROWN 



Fig. 3 

Photomicrograph of normal ligamentum flavum. 


emerges from the dural canal. An increase in the size of the ligament, a 
posterior protrusion of the disc, or a combination of the two, serves to 
compress the nerve root at this point (Fig. 1). Enlargement of the liga- 
ment may be generalized, although sometimes it is unilateral (Fig. 2), 
and it probably results from two factors, — namely, injury and scar tissue. 
Normal ligaments are composed entirely of yellow elastic fibers (Fig. 3) 
and grossly have considei'able elasticity. Even at necropsy, however, 
we have observed a bulbous expansion of the ends of the ligaments when 
they have been torn during removal. It seems likely that at the time 
of the injury — whether minor or severe — rupture of some of the elastic 
fibers of the ligamenta flava occurs, allowing them some degree of ex- 
pansion. Subsequently, as repair takes place, scar tissue is formed with 
further enlargement of the ligaments, so that compression of the nerve 
roots may result. Such injury and replacement by scar tissue can be 
demonstrated microscopically after the surgical removal of the enlarged 
ligament (Fig. 4). Sections should be made a short distance from the 
points of attachment to the bone, so that normal fibrous tissue at these 
points will not be mistaken for scar tissue in the ligament. 

Treatment consists of laminectomy and a wide lateral removal of the 
enlarged ligament in order to free the nerve root from compression. As 
the lamina is removed, the ligament is seen immediately beneath it and. 


THE JOURNAL OF BONE AND JOINT SURGERY 



ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


329 



Fig. 4 

Case 1. W. F. L. Photomicrograpli demonstrating tlie tj’pieal fibrotic scarring 
and marked degeneration and derangement of the yellow elastic fibers. 

if the enlargement is generalized, the constriction of the dural sac is often 
striking. Normally the ligaments in the lumbar region are from two 
to three millimeters in thickness, but, in the more marked enlargements, 
they have measured as much as one centimeter. Tlie majoritj' arc not 
adherent to the dura, but in one instance (Ca.«e 7) the ligament was firmly 
bound down to it. No changes were noted in the laminae overlj'ing the 
enlarged ligaments. In all cases a careful search was made to determine 
the po.ssible presence of a ruptured intervertebral disc. In two cases, a 
very small prominence of the disc was found in association with the en- 
larged ligamentum flavum. These did not amount to real dislocations of 
the intervertebral disc and, alone, would not have been sufficient to 
produce compression of the nerve roots. Anj' undue prominence of the 
disc, however, serves to decrca.se tlie .size of tlie pa.ssage for tlie nerve 
root (Fig. 1), so that even a moderate enlargement of tlie ligament would 
compress the root against it. 

Ordinarily the laminae are removed liy rongeurs and the ligamenta 
flava are often removed with the bone. Consequiuitly it would be possi- 
ble to m-erlook an enlargement of the ligament and feel that no lesion 
had been present. It is likely that such a removal of an enlarged liga- 
nientum flavum e.xplains certain ca.ses in the past in which definite defects 
had been shown by the injection of liiiiodol. luit nothing w.-is found at 


'■OI,. x.\, NO, APItll. nos 








330 


H. A. BROWN 


operation to explain them. Nevertheless the symptoms were relieved 
after operation because of the decompressive effect of the laminectomy 
and of the simultaneous removal of an unsuspected enlarged ligamentum 
flavum. 

In most of our patients rapid relief of pain followed removal of the 
ligament. If the compression of the nerve root had been prolonged and 
severe, recovery from the alterations in sensation, motor power, and 
reflexes was gradual, as is the case in the recovery and regeneration of any 
peripheral nerve following trauma. 

REPORT OP CASES 

Case 1 . A fall on the buttocks was followed by low-back pain with 
unilateral sciatic radiation of seven months’ duration. The spinal fluid 
showed an increased protein content and roentgenographic examination 
demonstrated a defect in the column of lipiodol at the lumbosacral junc- 
tion. Removal of an enlarged ligamentum flavum gave relief of symptoms. 

W. F. L., male, twenty-six years of age, was seen first in September 1936. On 
July 26, 1936, the patient had slipped, landing with consideral)le force on the buttocks. 
There was no immediate complaint, but on the following day he noted an aching pain 
in the right buttock, with slight discomfort down the posterior aspect of the thigh. 
There was a gradual increase in the severity of the pain and it was aggravated by ac- 
tivity. Rest in a recumbent position afforded complete relief of symptoms. The 
patient was treated by heat, massage, and supportive measures, witliout improvement 
in the symptoms. 

Examination was made on September 6, 1936. Tliere was great limitation of 
forward bending, restriction of straight-leg raising on the right side to 45 degrees, and 
moderate tenderness of the sciatic nerve at the sacrosciatic notch. No muscle atrophy 
was present. The right Achilles-tendon reflex was decreased and some hypaesthesia was 
present over the posterior portion of the thigh and the posterolateral aspect of the lower 
extremity. Roentgenograms of the lumbosacral spine were negative. An injection of 
the sacral hiatus with normal salt solution gave temporary relief, but the symptoms 
gradually recurred with persistence of the same findings. In January 1937, spinal 
puncture was done; the hydrodynamics of the spinal fluid were normal; the total protein 
content was ninety-seven milligrams per 100 cubic centimeters. Injection with lipiodol 
and fluoroscopic studies demonstrated a constriction in the dural sac at the lumbosacral 
junction (Fig. 5). This was interpreted as representing a dislocation of an interverte- 
bral disc. 

Laminectomy was performed on February 17, 1937, and an enlarged ligamentum 
flavum was found constricting the dural sac at the lumbosacral junction. It was re- 
moved widely on both sides. Careful exploration showed no other pathological process. 
Great scarring of the ligament, with destruction and fragmentation of the elastic tissue, 
was shown by microscopic examination. The patient was immediately relieved of pain 
by the operation. His only residual complaint was an occasional slight sensation of 
numbness in the left leg upon undue activity. Motor power, sensation, and reflexes 
rapidly returned to normal. 

Case 2. Low-back pain with unilateral sciatic radiation for thirteen 
months followed an indefinite injury to the back. Examination with 
lipiodol was only suggestive of a defect between the fourth and fifth 
lumbar vertebrae. Removal of an enlarged ligamentum flavum (uni- 
lateral) was followed by improvement. 

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331 


N. H., male, twenty-eight j'ears of age, a bookkeeper, entered the hospital on August 
24, 1936, complaining of pain low in the back on the left side, with typical sciatic radia- 
tion into the left lower extremity. The patient had first noticed pain in the back six 
months prior to entry, particularly after long automobile drives. Three months later, 
after spading, the pain had radiated down the posterior aspect of the left lower e.xtremity, 
extending into the calf and the ankle. Following this, flexion or rotation of the spine 
aggravated the pain. The left leg tired easily. Very little relief was obtained by rest 
in bed. The only history of injury in this case was of an automobile accident a year 
before entry, but no definite injury to the patient’s back was noted at the time. 

There was marked bilateral limitation of straight-leg raising; the left gluteal muscles 
were somewhat flabby; the power of the left leg was approximately equal to that of the 
right. The left patellar-tendon and Achilles-tendon reflexes were less active than the 
right. No sensory disturbance was noted. Jugular compression produced pain in 
the left leg. Roentgenographic examination showed six lumbar vertebrae with sacraliza- 
tion of the last segment. Spinal puncture caused an unusual amount of pain when the 
needle compressed the dura; the hydrodynamics of the spinal fluid were normal. Lipio- 
dol was injected, but fluoroscopic studies were negative. 

The patient was treated by manipulation and traction, without relief. Six weeks 
later, the fluoroscopic studies were repeated and were suggestive of a defect at the level 
between the fourth and fifth lumbar vertebrae on the left. In view of the persistent 
symptoms, the positive neurological findings, and the failure to obtain relief by con- 
servative measures, laminectomy was decided on and was done on March 10, 1937. 
A moderate enlargement of the ligamentum flavum was found on the left side between 
the fourth and fifth lumbar vertebrae. Careful search of the canal showed no evidence 
of a ruptured intervertebral disc. On microscopic e.xamination of the enlarged ligament, 
damage to the elastic tissue and replacement by scar were found, as shown in Figure 4. 
The patient had much less pain after operation, although he was not entirely relieved 



Fig. 5 

Case 1. AV. F. L. The use of lipiodol 
ilcmonst rales a defect at tlie lunibo.=3cral 
junction. 



Case 3. J. G. Tlierc is a 
sliglit defect in tlie column of 
lipiodo! l>etween the fourth and 
fifth lumbar vertebrae on the left. 


voi.. XX. xo. Ariiii. loas 





Fig. 12 

Case 4. Preoperative spine-marker roentgenogram, with patient in wedging jacket. 


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ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


333 


hiatus with novocain seemed to aggravate the pain. Numbness appeared over the outer 
aspect of the lower part of the left leg and the patient began to notice weakness of the 
anterior tibial muscles. 

E.\amination was done on March 12, 1937. There was no tenderness in the lower 
part of the back. Forward bending was markedlj' restricted and straight-leg raising 
on the left was limited to 25 degrees; no atrophj' was present; power in the anterior 
tibial muscles was considerablj’’ lessened. There was a decrease in sensation along the 
lateral side of the leg and the dorsum of the foot. The left AchUles-tendon reflex was 
absent. Roentgenograms of the lumbosacral region showed no signs of trauma. The 
hj'drodynamics of the spinal fluid were normal. Lipiodol demonstrated a verj' marked 
constriction of the meningeal sac between the fourth and fifth lumbar vertebrae 
(Fig. 7). An enlarged ligamentum flavum was suspected before operation in this case. 

Laminectomj' was done on April 15, 1937, and an unusually large ligament was 
found, producing a uniform constriction of the dural sac and its contents on botli sides. 
An e.xtensive removal was done, care being taken that the lateralmost part of the liga- 
ment was removed. The fifth lumbar root on the left was swollen. No evidence of a 
ruptured intervertebral disc was found. A spinal fusion was done following laminectomy. 



Fig. 7 

Case -1. T. O’C. Tliore is a uniform ron-trietion of tlie chini! sac hetwer-n 
tlic fourth and fifth lumbar vertebrae. 


voi„ XX. xo. .\ruii. ip.is 




332 


H. A. BROWN 


of it. He returned to work about six weeks after operation and lias continued to per- 
form his regular duties. Straight-leg raising has greatly improved and, at the present 
time, there is no evidence of motor, reflex, or sensory change. The residual discomfort 
in this case may be explained by a failure to remove the ligament sufficiently far laterally 
to decompress the nez-ve z-oot completely near the intervertebi-al foi-amen. 

Case 3. LoAV-back pain Avith unilateral sciatic radiation of five 
months’ duration occurred after torsion of the spine. The protein con- 
tent of the spinal fluid Avas increased and lipiodol shoAved a unilateral 
defect betAveen the fourth and fifth lumbar A’^ertebrae. An enlarged 
ligamentum flaAmm (unilateral) AA-as I’emoA'^ed and a prominent inter- 
vertebral disc Avas found behind the nerve root. Complete relief of signs 
and symptoms folloAA^ed operation. 

J. G., male, twenty-four yeai-s of age, entered the hospital in March 1937. In 
October 1936, the patient had leaned inside an automobile to wipe a windshield. He 
noted a snapping sensation in the lower part of the back and complained of pain low 
in the back immediately thereafter. Five days later the pain radiated over the sciatic 
distribution into the left lower exti-emity. When the patient was recumbent, the 
pain subsided, but it recurred immediatelj’^ on weight-bearing. He had noted no numb- 
ness or motor weakness. 

Examination on Januai’y 13, 1937, showed no spasm of the muscles low in the back, 
although there was tenderness between the fourth and fifth lumbar vertebrae. Jarring, 
at this point, produced some degree of pain in the left leg. No muscle atrophy was 
present, but there was slight weakness of the left extensor hallucis longus. Sensation 
was normal; the left Achilles-tendon reflex was deci’eased. Roentgenographic e-xamina- 
tion of the lumbosacral region was negative. Spinal puncture was done, showing normal 
hydrodynamics of the spinal fluid; the total protein was fifty-seven milligrams per 100 
cubic centimeters. Lipiodol studies under the fluoroscope demonstrated a very slight 
defect between the fourth and fifth lumbar vertebrae on the left side (Fig. 6). The de- 
fect Avas so slight that further conservative measures were tried. Tz’action gave tem- 
porary improvement, but weight-beai'ing immediately brought on pain low in the back 
and in the leg. 

Laminectomy Avas peilormed on March 15, 1937. The ligamentum flavum on the 
left side AA'as enlarged and the increase in size AA'as most evident in the lateral portion 
adjacent to the fifth lumbar root. FolloAving the i-emoval of the enlarged ligament, 
inspection behind the root shoAved a very slight prominence of the intervertebral disc 
at that point. This prominence, in itself, Avould not have produced symptoms, but the 
combination of the enlarged ligament and the prominence of the disc undoubtedly did 
cause them. The patient’s pain Avas immediately relieved, and the reflexes gradually 
returned to normal. He Avent back to his regular AA’ork about tAvo months after operation 
and has had no recurrence of pain. 

Case 4 - -A- fall on the buttocks preceded loAA'^-back pain AAdth uni- 

lateral sciatic radiation of fourteen months’ duration. Lipiodol demon- 
strated a generalized constriction of the dural sac. An enlarged ligament 
Avas remoAmd, AAuth relief of pain and gradual improvement in the motor 
and sensory loss. 

T. O’C., male, fifty-five years of age, AA’as injured on February 29, 1936, A\’hen his 
left foot slipped into a pit and he dropped sharply to the ground, striking the but- 
tocks. He had immediate pain Ioav in the back, AA’hich persisted in spite of constant 
treatment. It AA’as not until August 1936 that he first began to have radiation of pain 
over the distribution of the left sciatic nerve, extending to the ankle. A manipulation 
at this time resulted in temporary improA'eraent. Later, an injection of the sacra 

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ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


335 



Fig. 9 


Case 6. S. A. Anteropos- 
terior roentgenogram shon’ing 
the marked constriction of tlie 
dural sac between the fourth 
and fifth lumbar vertebrae. 


Case C. 


Fig. 10 

S. A. Lateral view. 


This prominence, in itself, was not sufficient to 
produce the degree of compre.'^sion whicii was found. 
The patient has liad considerable relief of 
pain. He has occasional paraestiiesia in the area of altered sen.=ation and the right 
Achilles-tendon reflex is still below normal. Epicritic sensibility is improving. His 
activity is being increased gradually. When one considers the duration and severity of 
compression of the spinal root, progress has been satisfactory. 


Case G. Low-back pain with bilateral .sciatic radiation followed a 
tliroct injury to the back, and a .subsequent increa.se in .syinplom.s occurred 
after fle.xion of the spine. The protein content of the spinal fluid was in- 
creased. Lipiodol showed a general constriction of the dural sac. A gen- 
eralized eidargeinent of the ligament was found at operation and relief 
was rapid after its removal. 

A., mule, forty-two years of age, was buried up to his chin m a cave-in of dirt m 
March 1930. Immediately following his relea.se he noteil pain low in the back, ulnch 
persisted. He attempted to continue hi- work and one month later, while bendiiig 
over, had a sudden snapping sensation low in the bark, with an incn-isc in pain. The 
pain then radiated down the posterior asiiects of both leg--, forcing him to stop work in 
Augu-t 1930. The leg- became weak and the patient wa- unable to stand. He na- 


VOI., XX. xo. 


Arnii. 1P3S 


334 


H. A. BROWN 


Microscopic examination of the ligament showed 
a fi-agmentation of the elastic fibers with an 
increase in connective tissue. The pain was 
relieved immecliatelj’ and the patient is increasing 
his activities steadil 3 \ There is still some residual 
sensory decrease and the left Achilles-tendon 
reflex has not yet returned to normal. 

Case 5. The patient had experienced 
iow-back pain with unilateral sciatic ra- 
diation after a direct injury to the spine 
during the act of lifting; this pain had 
jrersisted for twenty-three months. Lip- 
iodol demonstrated a unilateral defect 
between the fourth and fifth lumbar 
vertebrae. An enlarged ligament and a 
prominent intervertebral disc were found 
at operation. Imi^rovement has been 
gradual. 

S. C., male, thirty-seven years of age, while 
lifting a packing case on May 28, 1935, had slipped 
and fallen backward, striking his back against a 
hard object. He had immediate pain low in the 
back, chiefly on the right side and extending into 
Fig. 8 die right hip. The pain radiated down the pos- 

Case 5. S. C. There is a slight The leg felt some- 

defect between the fourth and fifth "'hat numb and heavy, and the patient e.xperienced 
lumbar vertebrae. some difficulty in motor control. Conservative 

measures, such as heat and rest, were tried without 
improvement. In January 193G, because of the continuation of symptoms, the trans- 
verse process of the fifth lumbar vertebra was removed. No impi’ovement followed; 
in fact the patient believed that the pain and weakness of the right lower extremity 
were gradually increasing. 

Examination on August 4, 1936, showed no spasm of the muscles low in the back; 
movements of the back were performed fairly well in all diz’ections. Straight-leg raising 
on the right side showed only slight limitation. The right thigh was two inches less in 
circumference than the left, and the right calf one and five-eighths inches smaller than 
the left. The patient had had a compound fracture of this leg with involvement of the 
common peroneal nerve, which accounted for some of the atrophy. Motor power was 
generally decreased in the right leg. The anterior tibial muscles were much weaker in 
proportion than the others. The right Achilles-tendon reflex was decreased. Some 
sensory decrease was present on the lateral and posterior aspects of the right lower leg. 
Roentgenographic examinations were negative e.xcept for the absence of the transverse 
process removed at operation. The patient was reexamined on March 24, 1937, with 
essentially the same findings; his complaints had not changed. The hydrodynamics of 
the spinal fluid were normal; the total protein was forty-five milligrams per 100 cubic 
centimeters. Injection of lipiodol demonstrated a slight defect between the fourth and 
fifth lumbar vertebrae, suggestive of rupture of an intervertebral disc (Fig. 8). 

Laminectomy was done on April 24, 1937, and an enlarged ligamentum flavum was 
found between the fourth and fifth lumbar vertebrae. The enlargement was more pro- 
nounced on the right side. A wide removal of the ligament, including its lateral portion, 
exposed the fifth lumbar root which was swollen. The intervertebral disc ventral to 
this root was slightly prominent, but inspection of the area showed no real dislocation. 

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ENLARGEMENT OF THE LIGAMENTUM FLAVUM 


337 


R. P., male, fifty years of age, a physician, had begun to have lumbar backache and 
to suffer occasional attacks of acute pain in 1929. This pain had been aggravated by 
movement and relieved by rest in bed. In Januarj' 1930, he had had a recurrence of 
severe backache with left sciatic pain. During the ne.vt four r-ears he had assumed an 
abnormal posture in order to reduce the frequency and severity of pain. In March 1935, 
he had had a severe attack of pain with radiation down the outer aspect of the left 
leg into the ankle. Another attack had occurred in December 1936. 

Examination was made in Januarj' 1937. The left leg was colder than the right. 
Hyperhidrosis was noted from the toes to the middle of the calf on the left. Coughing, 
straining, and sneezing aggravated the pain. When examined again on Jul3' 28, 1937, 
the left leg was still cold, and pulsation of the left dorsalis pedis arter3'^ was absent. 
These indicated some coincidental vascular disturbance. Power in the left leg was 
markedty decreased, particularl3'- with reference to dorsiflexion of the left foot and great 
toe. The left patellar-tendon and Achilles-tendon reflexes were slightl3’^ more active 
than the right. The left calf was a little smaller than the right. There was a painful 
hypaesthesia over the dorsum of the left foot and the anterolateral aspect of the lower 
leg, and areas of hypaesthesia were present in both calves. The h3’drod3mamics of the 
spinal fluid were normal. Lipiodol studies demonstrated a filling defect of the dural 
sac on the left side between the fourth and fifth lumbar vertebrae (Fig. 11). 

Laminectom3' was done on August 9, 1937. An enlargement of the ligamentum 
flavum was found, and the ligament was densety adherent to the dura. The fifth lumbar 
root on the left was somewhat adherent and its dural sheath was encompassed b3' scar 
tissue. Microscopic examination of the ligament demonstrated the fibrotic scarring and 
marked degeneration and derangement of the 3'ellow elastic fibers common to tliis con- 
dition. The patient has had relief from pain, but it is too soon after operation to c.xpoct 
much alteration with regard to power, sensation, and reflexes. 

COMMENT 

Although sufficient time has not elapsed to permit a report on the 
end results in all of our patients, there has been relief from severe pain 
in all, and improvement has been continuous to the present time. It is 
evident also that early diagnosis and operative treatment, before com- 
pression of the nerve roots has been prolonged, will undoubtodlj' produce 
more rapid and complete rccover3^ 

Ob^-iously lipiodol studies should not be resorted to in all ])atients 
who have low-back pain with sciatic radiation. A thorough trial of 
conservative measures is indicated unle.ss increasing evidences of neuro- 
logical involvement are present. All of our patients had been treated 
previously bj' conseiwative orthopaedic measures, and lipiodol studies 
were undertaken because of per.sistcnt .signs and .sj'inptoins in spite of 
treatment. 


SUM.MARY 

Enlargement of the ligamentum flavum is a clinical entitj- producing 
low-back iiain with sciatic radiation. Trauma of rclativeh' slight degree 
was the etiological factor in the majority of our patients. Pathoiogie.-d 
changes in the involved ligaments were demonstrated micro<eoi)ieall3’. 

The clinical sjuidrome is difficult to differentiate' from lunibo<;icral 
or saero-iliac disorders, and lijiiodol studies are rerpiired in order to n'.-ich 
a final diagnosis. It is seldom po.-.-ible to flifferentiate the fiefects in 

voi,. XX. xo. :. .M’uii. it'.ts 



336 


H. A. BROWN 


placed in traction wliich seemed to give some temporaiy improvement, altiiough the 
symptoms again became woi'se on weight-bearing. 

Examination was done on Marcli 29, 1937. The patient complained of severe pain 
low in the back with radiation to both hips and occasional shocklike pains in both legs. 
The entire lumbar spine was hyper.scnsitivc and movements of the back were greatly 
restricted in all directions. The patient walked with a guarded gait, favoring tlic right 
leg. No muscle atrophy was present in cither leg. Tliere was motor weakness of all 
muscles in both lower exti-emities, most pronounced on the left. Pain inhibited some 
muscle movements. There was a slight dccrca.se in sensation over the right buttock. 
The right patellar-tendon and Achilles-tendon reflc.xcs were more active than the left. 
Roentgenograms of the lumbosacral region were negative. Spinal puncture showed 
normal hydrodynamics of the spinal fluid; the total piotein was 110 milligrams per 100 
cubic centimeters. Lipiodol studies demon.strated a marked obstruction between the 
fourth and fifth lumbar vertebrae (Fig.s. 9 and 10). A small amount of lipiodol passed 
down along the riglit side of the dural sac. 

Laminectomy was done on May 7, 1037. The ligamentum flavum in this case was 
the most enlarged in our series, — it measured slightly over one centimeter in thickness. 
The dui'al sac and its contents were greatlj' constricted by the enlarged ligament and, 
even after removal of the ligament, the dural sac was found to be partR constricted, 

as was the underlying 
aiachnoid. A spinal fusion 
was done following the 
Iaminectom 3 ^ Microscopic 
e.xamination of the ligament 
showed areas in which the 
3 'cllow clastic fibers were 
fi'ngmented and replaced by 
fibrous connective tissue. A 
few areas of perivascular 
l 3 ’mphoc 3 'tic infiltration were 
seen. The patient was im- 
mediatel 3 ’^ relieved of pain 
and has been up and about 
without a recurrence of 
s 3 unptoms. His activit3' is 
gradually being increased and 
his progress has been satis- 
factory. 

Case 7. Low-back 
2 ?ain with unilateral sci- 
atic radiation was pres- 
ent for eight years. 
There was no antecedent 
trauma. Lifjiodol dem- 
onstrated a unilateral 
defect between the 
fourth and fifth lumbar 
vertebrae. An enlarged 
ligament, adherent to 
the dura, was removed 

Case 7. R- F- There is a defect in the column of {^t operation, with relief 
lipiodol between the fourth and fifth lumbar vertebrae 
on the left. 

THE JOURNAL OF BONE AND JOINT SURGERY 



Fig. 11 



A PROCEDURE FOR THE CORRECTION OF INTERNAL 
ROTATION OF THE THIGH IN SPASTIC PARALYSIS * 

BY HERBERT A. DURHAM, M.D., SHREVEPORT, LOUISIANA 

Those surgeons who have had much experience with the treatment 
of spastic cerebral paralysis are familiar with the numerous and diverse 
problems that arise when the correction of associated deforming contrac- 
tures is undertaken. That these problems have not all been satisfactorily 
solved is shown by the wide variety of suggested operations for the cor- 
rection of these contractures. 

It is not the purpose of this article to discuss spastic contractures in 
general, but, rather, to deal with a specific contracture which, in the 
experience of the writer, has for a long time been recognized as disabling 
and difficult to overcome, — namely, internal rotation of the thigh. 
Numerous devices and procedures have been instituted to correct this 
deformity with heretofore unsatisfactory results. 

While internal-rotation deformity may exist in the absence of other 
contractures around the hip, it is by far more frequently associated with 
the commonly found flexion-adduction contractures of the thigh, and, thus 
effectively masked, it does not become manifest to its full extent until 
the flexion and adduction have been corrected. Even then it maj’- escape 
notice when the patient is recumbent, but when he stands it will bo 
observed that one or both thighs rotate inward and flex slightly at the 
hip and the knee. This position interferes greatly with locomotion 
and renders the gait clums}’- and un- 
sightly. 

The apparent cause of this was 
brought to the author’s attention sev- 
eral years ago by a patient, who, after 
release of the flexors and adductors 
of the thigh and lengthening of the 
hamstrings, exhibited an unusual de- 
gree of internal rotation of the thigh 
both in recumbency and when stand- 
ing. Upon attempting to passively 
rotate the thigh externally, it was 
noted that the internal rotators were 
extremely tense and .'^iiastic, prevent- 
ing passive rotation to a neutral posi- 
tion. This jjrompted a careful ana- 
tomical study of jjaticnts in wliom the 
correction of adductor and flexor 

* Rp.'iil !il tlio .Vnnual McotiiiR of tlic American .Vcatirniy of Ortliop.')r.<iir 
Ix)S .\iipclp.-;, California, .lamiary IS, 1035. 



I'lG. 1 

Showini: insertion of the clutete 
inedius and tlie chitens ininimu- to tlie 
femond trochanter. 


VOt. NX. NO. 2, .\I'niI. lo.rs 




338 


H. A. BROWN 


the column of lipiodol from those produced by rupture of an intervertebral 
disc. Compression of nerve roots by the enlarged ligament produces 
the symptoms and signs. After their exit from the dura, the nerve roots 
lie in the very narrow space betAveen the ligamentum flavum and the inter- 
vertebral disc. Even a slight enlargement of the ligament, a posterior 
protrusion of the intervertebral disc, or a combination of the two, will 
produce compression of the nerve roots. 

Seven patients with enlargement of the ligamentum flavum Avere 
operated on over a period of seven months. This AA^ould indicate that 
the condition is much more common than is supposed and that many 
such cases have undoubtedly been overlooked in the past. Operative 
remoAml of the enlarged ligament produced prompt relief of pain AAdth 
gradual improAmment in the impaired motor and sensory functions. 

Note: The author is indebted to Dr. John Saunders of the Department of Anatomy for 
the use of the anatomical specimen in Figure 1. 

REFERENCES 

Abbott, W. D. : Compression of the Cauda Equina by Ligamentum Flavum. J. Am- 
Med. Assn., CVI, 2129, 193G. 

Elsberg, C. a. ; Experiences in Spinal Surgciy. Observations upon 60 Laminectomies 
for Spinal Disease. Surg. Gynec. Obstet., XVI, 117, 1913. 

Diagnosis and Treatment of Surgical Diseases of the Spinal Cord and 
Its Membranes, p. 230. Philadelphia, W. B. Saunders Co., 1916. 

Hampton, A. 0., and Robinson, J. M.: The Roentgcnographic Demonstration of Rup- 
ture of the Intervertebral Disc into the Spinal Canal after the Injection of Lipiodol 
with Special Reference to Unilateral Lumbar Lesions Accompanied bj'- Low Back 
Pain Avith “Sciatic” Radiation. Am. J. Roentgenol., XXXVI, 782, 1936. 
PuusEPP, L. : Kompression der Cauda equina durch das verdickte Ligamentum flavum. 

Tumorsymptome, Operation, Pleilung. Folia Neuropath. Estoniana, XII, 38, 1932. 
Spuhling, R. G. ; Mayfield, F. H.; and Rogers, J. B.; HA'pertroply of the Ligamenta 
Flava as a Cause of Low Back Pain. J. Am. Med. Assn., CIX, 928, 1937. 

Towns, E. B., and Reichert, F. L.: Compression of the Lumbosacral Roots of the 
Spinal Cord b 3 " Thickened Ligamenta Flava. Ann. Surg., XCIV, 327, 1931. 


THE JOURNAL OF BONE AND JOINT SURGEBY 




340 


H. A. DURHAM 


spasm had given disappointing results, and it was found that in prac- 
tically all of those studied the same contracture or overactivity of the 
internal-rotator mechanism was 



Shrmers’ Hospital for Crippled Children during the past six years, twenty, 
or approximately 25 per cent., had internal rotation of the thighs suffi- 
cient to interfere materially with walking. This indicates that spastic 
contracture of the internal rotators of the thiahs is one of the common 



Fig. 4 

Showing the portion of the gluteus medius 
and of the lower border of the gluteus mini- 
mus which is to be divided. 


sequelae of spastic paralysis of 
the lower extremities. 

Since the anterior fibers of 
the gluteus medius and the glu- 
teus minimus, assisted by the ten- 
sor fasciae femoris, constitute the 
effective internal-rotator mechan- 
ism of the thigh, it seemed logical 
to assume that a release of this 
mechanism would have a benefi- 
cial influence on the rotation 
deformity. Although the gluteus 
medius and the gluteus minimus 
are also the most important ab- 
ductors of the thigh, it was rea- 
soned that this action would not 
be seriously affected by a division 
of that part of the muscles which 
is attached anterior to the tip of 


THE JOURNAL OF BONE AND JOINT SURGERY 





intehnal rotation of the thigh in spastic paralysis 341 


the greater trochanter, 
since the remaining su- 
perior fibers, still being 
spastic, would in all prob- 
ability be sufficiently 
strong to maintain effec- 
tive lateral balance of the 
pelvis in walking. 

ANATOIMICAL 

CONSIDERATIONS 

As previously stated, 
the most powerful rota- 
tors of the thigh are the 
gluteus medius, the glu- 
teus minimus, and the 
tensor fasciae femoris. 

The distal fibers of the Fig. 5 

adductor magnus and the I: Posterior fibers of the gluteus medius. 

iliopsoas are mentioned Se‘g“uteusmSus^ 

by some anatomists as ill: Capsule of the hip joint. 

assisting in internal rota- 

tion of the thigh, but, 

because of their location and attachment to the femur, their function, as 
such, is almost negligible, and they may be ignored as far as pla 5 ’'ing anj’’ 
part in the production of the deformity in que.stion is concerned. The 
only true internal rotators of the thigh, then, are the gluteus medius, the 
gluteus minimus, and the tensor 



fasciae femoris, with the greater part 
of this function being carried out by 
the two gluteal muscles because of 
their direct insertion to tlie greater 
trochanter of the femur. In patients 
with pronounced internal rotation of 
the femur, the anterior portion of 
these museles can be felt as heavy 
cords whicli stand out prominently 
when an attempt is made to passively 
rotate the femur externally. 

The fan-shaped gluteus medius, 
arising from the dorsal surface of the 
ilium and from the fascia lata on it- 
anterior surface, converges to the 
greater trochanter to be inserted by a 
strong short tendon into a well- 
marked diagonal line on its lateral 



Fig. 0 

Po'Tf>iK'r:!tivc of in 

pl-ivicr. 


VOL, X\-. NO. 2 . .vrnlt. 




342 


H. A. DURHAM 



THE JOURNAL OF 


BONE AND JOINT SURGERY 




INTERNAL ROTATION OF THE THIGH IN SPASTIC PARALTSIS 343 

surface. (See Figure 1.) The gluteus minimus, also a fan-shaped 
muscle, arising under cover of the gluteus medius and from the dorsal 
surface of the ilium, converges to the anterosuperior angle of the greater 
trochanter and covers the superior aspect of the capsule of the hip joint. 
It is inserted into the anterosuperior surface of the greater trochanter. 
Both muscles are fairly superficial and readily accessible at their points of 
insertion, being covered only by skin, subcutaneous fat, fascia, and tensor 
fasciae latae. 


OPERATIVE TECHNIQUE 

The operative technique for the release of these muscles is relatively 
simple. A short diagonal incision is made from behind forward immedi- 
ately over the greater trochanter. (See Figure 2.) The tensor fasciae 
latae is divided in the line of the skin incision and retracted. (See Figure 
3.) The gluteus medius and the gluteus minimus are exposed at their 
insertions into the greater trochanter. By rotating the thigh externally, 
one can put these muscles under tension, and they are thus easily identi- 
fied. A grooved director or dissector is passed under that portion of the 
tendons which is inserted anterior and below the tip of the trochanter 
(Fig. 4). The tendons are then divided close to their insertions (Fig. 5). 
Any remaining tight fascial bands are easily detected by palpation and are 
likewise divided. The thigh can then be put into complete unresisted 
external rotation. If the fascia lata is tense and separates widely when the 
thigh is rotated outward, it is left unsutured and allowed to retract; 
otherwise it may be reapproximated. The subcutaneous fat and the skin 
are closed by separate layers of sutures. 

Plaster immobilization is used to maintain the thigli in abduction 
and full external rotation. When the operation is unilateral, a single 
hip spica is sufficient. When the operation is bilateral, it is nece.?sary to 
put on two long leg casts with a connecting bar to maintain the external 
rotation. (See Figure 6.) The casts are removed at the end of six or 
eight weeks, at which time physiotherapy and walking exercises are be- 
gun, provided the other necessary corrective procedures have been carried 
out. 

It is conceivable that in extreme degrees of rotation of long duration 
there might exist some developmental shortening of the anterior portion 
of the hip capsule, particularly the iliotrochanteric and the iliofemoral 
portions of the Y-ligament. The author has never found this condition 
existing, but, should it be found, he sees no reason why the tight bands 
could not be safelj’’ divided. 


END RESULTS 

During the past six years, twenty patients with this deformitj' have 
been operated upon. The internal-rotation contracture was bilateral in 
twelve patients, making the total number of operations thirty-two. The 
patients have been kejit under observation for periods varying from six 


VOL. XX xo. 2. .\rniL ims 



344 


H. A. DURHAM 


months to six years. Thus far the correction has been maintained in 
all of the cases. There have been no disturbances of locomotion that could 
be attributed to gluteal weakness. 

SUMMARY AND CONCLUSIONS 

1. Internal rotation of the thigh is a common, disabling, and per- 
sistent deformity in patients with .spastic paralysis. 

2. It is found mainly in conjunction with the more obvious flexor 
and adductor spasm, and for that reason its importance as a separate 
factor is apt to be overlooked. 

3. The operation of anterior gluteal release is anatomically sound 
and technically simple. 

4. Since it has given uniformly satisfactory results in a series of 
twenty patients, the writer has no he.sitancy in presenting it as a helpful 
addition to the numerous surgical procedures in use for the relief of spastic 
contractures. 


The author wislies to express liis grateful appreciation and thanks to Dr. Gene D. 
Caldwell for the illustrative drawings and other valuable assistance in assembling the 
material. 


the journal of bone and joint surgeri 



EXPERIMENTAL NON-CALCIFICATION OF CALLUS 
SIMULATING NON-UNION 


BY A. W. HAM, M.B., F. F. TISDALB, M.D., F.R.C.P. (c.), AND 

T. G. H. DRAKE, M.B., F.R.C.P.(c.), TORONTO, ONTARIO, CANADA 

From the Departments of Anatomy and Paediatrics, University of Toronto 

Complete bone repair is the outcome of two processes which usuall}’- 
concur, — callus formation and calcification. In this investigation we 
separated these two processes by experimental means, so that we were 
able to produce uncalcified callus. Although uncalcified callus did not 
show up in roentgenograms (the picture being that of non-union), his- 
tological studies revealed it to be bony in character, as did the fact that it 
precipitously calcified under a changed experimental procedure. Thus 
this experiment illustrates that complete bone repair can be prevented by 
the failure of the second process (calcification), and that the two processes 
concerned in bone repair are controlled by entirely different factors. 

MATERIAL AND METHODS 

Twenty normal rats, four weeks old. were used in the experiment. 
These were fed Steenbock’s rickets-producing diet consisting of 76 per 
cent, ground whole corn, 20 per cent, wheat gluten, 3 per cent, calcium 
carbonate, and 1 per cent, sodium chloride, plus 5 per cent, dried brewer's 
yeast. After the animals had lived on this diet for one week, they were 
anaesthetized and the right foreleg of each animal was broken. The frac- 
ture included both the radius and the ulna. After this procedure, the 
animals lived on the same diet for three weeks, when ten of them were 
killed, x-rayed, and autopsied. This group of animals will hereafter be 
called “Group A”. The ten remaining animals were allowed to live four 
days longer, and in this period each received, in addition to the diet al- 
ready outlined, about 75 international vitamin-D units in the form of 
viosterol. At the end of this time, they were killed, x-rayed, and autoj)- 
.sied. This group of animals will hereafter be called “Group B”. 

The two groups of animals were treated identically with the excep- 
tions that the animals of Group B lived twenty-five day.^ instead of 
twenty-one days and received vitamin D during the last four days of life. 

The blood from the animals of each group was jjonled for chemical 
examination. The right femora of the animals of each group were pooled 
for bone-ash estimations. The fractured foreleg of each animal w.ns 
x-rayed, after which it was removed and fixed and decalcified in Bonin's 
fluid and sectioned by the jiaraffin method. Serial sections were jircparcd 
m many cases in order to obtain a comiirehensive view of the fracture 
area. They were stained with hemato.xylin and c-o-in. 

voi., \o 2. .\run. ims 



346 


A. W. HAM, F. F. TISDALL, AND T. G. H. DRAKE 


OBSERVATIONS 

Chemical Findings 

The average values found for the calcium and inorganic phosphorus 
in the whole blood, as well as the percentage of ash in the leg bones of the 
animals, are given in Table I. 


TABLE 1 
Chemical Findings 



Blood Calcium 
{Milligrams per 
100 Cubic 
Ccnlimclcrs) 

Blood Phosphorus 
{Milligrams per 
100 Cubic 
Centimeters) 

Bone Ash 
{Per Cent.) 

Group A 

10.3 

2.5 

30.3 

Group B 

10.4 

S.S 

31.3 



Roentgenogra-phic Fin din gs 

As may be seen in the two left-hand columns of Figure 1, roentgeno- 
grams of the ten fractures in the animals of Group A showed little evi- 
dence of callus. In only three of the ten fractures was any trace of callus 
seen, and seven of the ten fractures presented the picture of non-union. 

The two right-hand columns of Figure 1 present the roentgenograms 
of the ten fractures in Group B, Seven of these showed good callus 
formation. 

The difference between the typical x-ray appearance of animals of 
Groups A and B is apparent in Figures 2-A and 2-B ivhich are enlarge- 
ments of the original roentgenograms. Figure 2-A shows a typical fracture 
in Group A, while Figure 2-B shows a typical fracture in Group B. 

Microscopic Findings 

Whereas the x-ray appearance of the fractures in Group A differed 
markedly from those of Group B, the sections of these fractures on micro- 
scopic examination proved to be strikingly similar, (See Figures 3-A and 
3-B,) At the site of fracture in both groups there was excellent organic 
callus formation. The repair was not of the sort termed fibrous union, 
because the callus was composed of the same organic constituents that are 
seen in the repair of a normal fracture, — namely, osteogenic tissue, a cer- 
tain amount of cartilage, a considerable amount of very young bone 
(usually termed "osteoid tissue”), and a certain amount of newly foime 
bone of a more mature appearance. If any difference existed in the 
microscopic appearance of the fractures in the two groups of animals, it 
was the tendency for the organic matrix in the calluses of the anima s o 
Group B to stain somewhat more deeply with hematoxylin. (This p le 
nomenon is usually considered indicative of calcification. We, however, 

THE JOURNAL OF BONE AND JOINT SURGERY 






NON-CALCIFICATION OF CALLUS 


347 


doubt the ability of hematoxylin to indicate very accurately the calcium 
content of tissues even when they are not decalcified, and we are com- 
pletely skeptical of its ability to indicate sites of calcification in decalcified 
material.) 



Fig. 1 


Tlio two U'ft-hond columii.s arc rnoiitRoiiOKrains of tlio fnictiin s in Croup .A. I'or 
th(‘ mort part tlicso prcsont tlio appcaraiirc of non-union, altlmucli licalmc liad l)i-< n 
taking place for three wia'ks while the animals were on a lieficieiit de t. Tiie two 
ri|;ht-liand cohnniis are nientiteiioKrams of similarly treatisl anima!-; in Croup 1!, 
except that these animals wen' alloweil to live four mon' d iys. <lunnc uhich time 
they leceived vitamin D. In this period a well-marked callus apjiearis! in tie- rn i- 
jority of fractunxs. 


VOl. NX, NO e Armi, tee 





348 


A. W. HAM, F. F. TISDALL, AND T. G. H. DRAKE 


That well-marked typical bone repair had occurred in the fracture 
areas of the animals of Grouj) A, oven though it did not show on x-ray, 
is illustrated in Figures 3-A and 3-B. Figure 3-A is a section of a frac- 
ture in an animal from Groujj A which showed no evidence of callus on 
roentgenographic examination. Figure 3-B is a typical section from a 
healing fracture in Group B. 

DISCUSSION 

The Reason for Using Two Groups of Animals 

In this experiment we wished to make observations on the blood and 
fractured bones of animals living for three weeks after the fracture on a 
deficient diet. We also wished to learn what changes would occur in these 
animals after the diet was changed. It is literally impossible to obtain 

these findings and have the animals 
firm afterward, so we could not get 
both sets of observations from any 
single animal. Hence we used two 
groups which, until three weeks after 
the fracture, were treated identically. 
At this time the animals in the first 
group, A, were killed, and the diet was 
changed in Group B which were kept 
for four more days. Thus observa- 
tions on Group A represent the 
state of affairs in Group B four 
days before the}'’ were killed, 
and the changes which oc- 
curred in that time must have 
been caused either by the four 
extra days’ healing or the 
changed diet. As four days 
was such a small fraction of 
the total time of the experiment, it seems logical to conclude that the 
differences in the findings between the animals of Groups A and B were 
caused by the vitamin D given in the four days at the end of the experiment. 

The Terms “Non-Union'' and “Non-Calcification" 

Like so many definitions in present-day use, certain of those used 
commonly in regard to fractures are decidedly inadequate. For instance, 
the terms “non-union” and “ununited fracture” are employed to indicate 
the absence of bony union. Hence “fibrous union” is an example of 
“non-union”. It is a problem to decide whether a fracture which 
is united by a callus, the organic constituents of which are similar to 
bone but which are not calcified, should be called “non-union”. To 
settle this question, it becomes necessary to decide whether bone tissue is 
distinguished from other tissues by its organic constituents or by its 

THE JOURNAL OF RONE AND JOINT SURGERI 



Fig. 2-B 

Example of fracture in Group B (enlarged). 



Fig. 2-A 

Example of fracture in Gi'oup A 
(enlarged). 




NON-CALCIFICATIOX OF CALLUS 


349 



Fig. 3-B 

l imin' ;?-A is a typical example of llie histolomeal appearance of a fnicture in an 
nnimal from (Iroiip A; Fipiire S-H shows a si-ction of a fracture in an animal from 
Group H. It is apparent that the administnition of vitamin D for four days did not 
markedlv ehaiiRe the histolopical appearance of the eallu*-' ti'-ue, uhicli i- ahuridant 
in hotli fractures. 


VOI, XX. NO c, .M'ltll. UOn 







350 


A. W. HAISI, F. F. TISDALL, AND T. G. H. DRAKE 


inorganic constituents. In this connection it should be pointed out that 
other tissues can calcify, taking up exactly the same salts that bone does, 
but this does not make these tissues into bone. For instance, calcified 
cartilage is not bone. Consequently, although bone is almost always 
calcified, and although calcification is its most impressive feature, it is not 
its distinguishing one. In the last analysis, bone is distinguished from 
other tissues by the character and arrangement of its organic constituents, 
and this experiment revealed that these are very similar in uncalcified 
and calcified bone (callus in Groups A and B). Thus we take the position 
that the fractures in Group A were examples of true bony union even 
though the bone was not calcified. Hence “non-calcification” is not 
“non-union”. 

Possible and Not Uncommon Misinterpretations of Action of So-Called 
“Calcifying Agents” 

The difference between the findings of Groups A and B existed in the 
x-ray appearances and the blood, and not in the histological sections. 
However, if the latter had not been studied, it would have been very easy 
to conclude from the x-ray appearances that vitamin D had caused a 
remarkable growth of callus in the four days when it was given. In- 
vestigation of the histological picture, however, revealed that a good 
organic callus -was in existence before the vitamin D was given and that 
the vitamin D had no effect on its organic structure. Hence vitamin D 
does not affect the growth of callus. What it does affect can also be 
readily misunderstood. If blood findings had not been available in this 
experiment, it would have been easy to conclude that vitamin D acted as 
a specific calcifying agent. However, reference to the blood-phosphorus 
figures reveals that this mineral existed in such small amounts in the blood 
previous to the vitamin-D administration that calcification could not 
occur. After vitamin D -was given, the blood-phosphorus level rose 
quicklj'- to a point wdiere normal calcification was able to proceed in the 
callus which was avid for a calcium-phosphate precipitate. Consequently 
vitamin D should not be thought of as a specific local calcifying agent, 
but rather as only one of the many factors concerned in affecting the 
general calcium and phosphorus metabolism. In this particular experi- 
ment it was a marginal factor. 

The Two Aspects of Bone Repair and the Factors Which Control Them 

As this experiment allowed the separation of the two processes the 
growth of callus and its calcification — it illustrates that the two processes 
are controlled by entirely different factors. Consequently, it is easy to 
see that there is little use in taking therapeutic measures to affect one 
process (for instance, calcification) when the other process is at fault. 
As a matter of fact, w^e know remarkably little about those factors which 
cause reparative tissue to grow when a bone is broken or even when any 
other tissue is injured. We are much better informed, however, m 

THE JOURNAL OF BONE AND JOINT SURGERY 



NON-CALCIFICATION OF CALLUS 


351 


regard to the factors which control the second aspect of bone repair, — 
namely, calcification. This process is now thought to occur in bone as 
follows: The fluids surrounding bone matrix are saturated with respect 
to calcium phosphate, but contain in addition both calcium and phos- 
phorus in other forms, some of those being bound organic compounds. 
Osteoblasts in the newly forming bone secrete the enzyme phosphatase 
which splits certain of those bound phosphates, so that additional phos- 
phate ions are liberated in the vicinity. As the solution is already satur- 
ated with calcium phosphate, the addition of extra phosphate ions, by 
mass action, drives down a precipitate of calcium phosphate (the precipi- 
tate is more complex, but this is disregarded for the sake of simplicity), 
and this precipitate is taken up by bone matrix which has a physico- 
chemical afiinity for it. 

Possibilitij of Non-Calcification in Human Cases 

This experiment suggests the possibility that the .x-ray picture seen 
in certain cases, which leads to the diagnosis of meager or tardy callus 
formation or even non-union, is at least partially accounted for by non- 
calcification of the callus. At first thought it might be considered that 
such a possibility could be immediately ruled out by determining the 
blood calcium and phosphorus level of the patient. Lest too hasty a 
decision be made upon this matter, it is well to remember that the state of 
these elements of the blood is just as important as are their amounts, and 
a great deal remains to be learned about the state of these minerals in the 
blood. To illustrate this point, an acidosis probably causes a change 
in the character of the calcium phosphates of the blood, shifting them to 
the more acid salts which are much more soluble and correspondingly 
more difficult to precipitate. However, we must await future investiga- 
tions before we can understand and perhaps remedy various disturbances 
of the state of the calcium and phosphorus of the blood which would 
prevent precipitation in bone even though the level of these substances 
in the blood is normal. In the meantime, although defective bone repair 
is probably almost always the result of the failure of the first process — 
the growth of a proper callus — it seems worth while to keep in mind the 
possibility that the x-raj"^ picture can result from a failure of the .second 
process. 


SUSIMAKY AND CONCLUSIONS 

In this study, fractures were produced in animals which were being 
fed a diet that deranged their calcium and phosphorus metabolism. 

At the end of three weeks, roentgenograms gave the impression that 
no union had occurred, but histological examination showed the presence 
of an excellent callus of bony tissue, although it was uncalcified. 

Similarly treated animals, allowed to live four day.s longer and given 
vitamin D during this period, showed a rajiid calcification of the bonv 
callus which was, of course, already in existence. This rajiid calcification 


voi., xx. NO. ?, Arnii. i?ss 



18 


F. L. BUTTE 


excellent, and the fusion solid. Had the eighth thoracic vertebra been 
included in the fusion in its overcorrected position, this would have neces- 
sitated a reversal of the upper thoracic compensatory curve for perfect 
alignment. The omission from tlie fusion of one of the vertebrae of the 
primary curve, which was successful in this case, would not have been safe 
had the patient been three or more years younger, as growth would be 
expected to cause an increase of deformity at this site. 

Case 5 {Figures I 4 , 16, and 16) 

V. P., female, aged seventeen years, had an "idiopathic” right tho- 
racic left lumbar scoliosis, the primary right thoracic curve extending 
from the fourth to the tAvelfth thoracic verteljra, with the apex at the 
eighth (Fig. 14). Marked decompensation and displacement of the trunk 
to the right and marked prominence of the left hip Avere noted. The pa- 
tient had worn plaster casts for two years before coming to this Clinic. 
A pelvic-tilt examination was not made, as it was not expected that the 
primary thoracic curvature could be corrected more than enough to restore 
compensation. 

Figure 15, the spine-marker roentgenogram, shows the iDOsition of the 
spine after correction in the jacket immediately before operation. To 
fuse the minimum area of the primary curve (the fourth to the twelfth 
thoracic) Avould probably have given a very satisfactory result. To in- 
clude one vertebra above and one A'^ertebra beloAv in this instance more 
nearly approaches the ideal fusion area extending from level vertebra to 
level vertebra with the transverse axis of each at right angles to the axis 
of the trunk. AlloAAung for slight loss of correction during the first year 
after operation, it Avas felt that this AAmuld not demand more straightening 
of the compensatory curA^e beloAA"^ than could be accomplished in this area. 
Therefore, in 1933, fusion in tAA^o stages AA^as done from the third thoracic 
to the first lumbar. 

Figure 16 shows the result three years and ten months later. There 
is marked improA’^ement in appeai’ance, although by actual measurement 
the primary curvature is reduced less than 50 per cent. The fusion mass 
is solid, maintaining nearly all the correction obtained in the jacket. It 
AAull be noticed, however, that there is now a slight prominence of the right 
hip Avith a slight shift of the trunk to the left, due to the fact that the lum- 
bar compensatory curA^e beloAA^ the fusion has not yet straightened enough 
for perfect alignment. In other Avords, for this particular case, inclusion 
of the first lumbar A'-ertebra resulted in someAAdiat excessive correction at 
the loAA^er end of the cui’A^e. Had a pelvic-tilt examination been made, 
AA^e should haA'^e knoAAUi Iioaa^ much, or how little, spontaneous straightening 
to expect in the lumbar curve and AAmuld probably have stopped the fusion 
inferiorly at the tAA^elfth thoracic A'-ertebra. 

COMMENT 

At the NeAv York Orthopaedic Dispensary and Hospital, from 1928 
to the present time, over 400 patients have had AA'edging-jacket correction 


THE JOURNAL OF BONE AND JOINT SURGERY 



PNEUMOROENTGENOGRAPHY OF THE KNEE JOINT * 


An Analysis of Fifty Cases 

BY PAUL A. QUAINTANCE, M.D., F.A.C.S., LOS ANGELES, CALIFORNIA 

A combination of insufflation with oxygen, carbon dioxide, or atmos- 
pheric air, and roentgenography has been used successfully in demon- 
strating and differentiating injuries to and diseases of the soft-tissue 
structures of the knee (Kleinberg, Balensweig, Bernstein and Arens, 
Friedrich, Rechtman, Cattaneo, and Simon, Hamilton, and Farrington). 
The writer is herewith reporting briefly his experience with pneumo- 
roentgenography as such an aid in diagnosis in fifty patients studied during 
the la.st seven years. 


INDICATIONS 

Pneumoroentgenography is indicated in cases of long standing, 
ivhen injury and locking are questionable and, also, when plain roentgeno- 
grams disclose no evidence of injury or reveal impacted fracture of the 
tuberosity of the tibia or avulsion fracture of the condyle of the femur. 
By this means is made possible differentiation of fractured, loose, or dis- 
placed menisci, injury to the cruciate ligaments, fracture of the spines of 
the tibia, chronic villous synovitis, hypertrophy of the fat pad, and loose 
bodies in the joint. The method is of value in localizing the seat of path- 
ology and in demonstrating multiple lesions or lesions of soft tissues, 
symptoms of which are masked by injuries to the bone. 

Reports in the literature and the author’s own limited e.xperience 
indicate that the procedure is harmless. However, Kleinberg, in 1927, 
reported a case of non-fatal pulmonarj’’ embolism following an unsuccessful 
attempt at insufflation of a knee by a ho.spital re.sidcnt. No reports of 
infections attributable to the procedure have come to the writer's atten- 
tion, and no infections have occurred in this series. One of the author’s 
patients had a fainting spell on the x-raj- table, witli recovery after a few 
minutes. 


TECHNIQUE 

Under local infiltration anaesthesia, witli the knee relaxed in slight 
flexion on the .x-ray taiile, the joint is insufllated with atmosplierie air. 
Any fluid present is as]nrated. A moderate degree of distention of the 
joint is effected by the injection of from 100 to 150 cnliic centimeters of air 
witli an ordinary Luer syringe and needle with a stoji-cock. 

Stereoscopic antero]iosterior and jiiain lateral roentgenograms are 

* .\n !il)l)r('vi:iti<)ii iif a paiicr read lieforc the IndU'Trial Mcilirine and .Sarxn n- .s. r- 
tion of tile California Medical .\ssoriation at llie tsixty-Fifth .\nnu;d .S.-- :on, Oir'iiadu, 
California, May 2o to 2S, 1930. 


VOI.. XX, N(>. 2. AT'HIl. IH'S 



352 


A. W. HAM, F. F. TISDALL, AND T. G. H. DRAKE 


of callus was noted in the roentgenograms. The histological appearance 
of the fractures changed little in this time. 

Non-calcification of a callus is not non-union, because bony union 
is judged as such by the character and arrangement of the organic con- 
stituents of callus and not by its mineral content. 

Vitamin D and other so-called calcifying agents do not control the 
formation or growth of a callus, and only indirectly affect its calcification. 

As this experiment clearly sejjarates the two phases of bone repair 
and illustrates that x-ray ap]3earances of healing can be prevented by a 
failure of calcification even though a good organic callus is present, it is 
futile to adopt therapeutic measures directed at one process when the 
other is at fault, because the two processes are controlled by entirely 
different factors. 

The possibility that certain cases of apparent meager or tardy union 
or even non-union in human beings are in reality cases of non-calcification 
should be considered. 


THE JOURNAL OF BONE AND-JOINT SURGERY 



PNEUMOROENTGENOGRAPHY OF THE KNEE JOINT 


355 


TABLE I 


Analysis of Twenty-Four Operations on the Knee 


Type and 
Location of 
Pathology 

Pneumoroentgeno- 
graphic Diagnosis 
No. of Cases 

Operative 
Findings 
No. of Cases 

Diagnosis 
Verified 
Per Cent. 

Remarks 

Fracture of 
meniscus: 
Medial 
Lateral 

11 

2 

— 13 

12 

2 

— 14 

71 

Four previously undiag- 
nosed fractures found at 
operation. In three cases 
no operation was per- 
formed. 

Displacement 
of meniscus: 
Medial 
Lateral 

11 

4 

~ 15 

9 

3 

— 12 

91 

One previously undiag- 
nosed case found at opera- 
tion. In four cases no 
operation was performed. 

Fracture- 
displacement 
of meniscus: 
Medial 
Lateral 

4 

1 

” 5 

4 

1 

~ 5 

100 


Loose bodies 

8 

3 

100 

In five cases no operation 
was performed. In one of 
tlie patients operated upon 
the plain x-ray had failed 
to show the loose body. 

Pedunculated 

bodies 

0 

1 

0 



with a direct blow. Five patients had slipped, ten had fallen, and two 
had stumbled. 

Forty-two patients complained of immediate pain in the knee; 
twenty-three were unable to extend the leg full}' immediately' after the 
accident. Three patients complained of having felt a click or snap, and 
four had noticed black and blue coloration. Recurrence of symptoms 
caused twenty-eight, or 56 per cent., of the patients to seek medical atten- 
tion weeks or months, and in one instance over three year.s, after tlic 
original injury. 

Plij’sical examination disclosed tenderness anteromedially in twenty- 
two patients, anterolaterally in five, medially in four, and laterally in two. 
Tliree had tenderness both medially and anteromedially and two had 
tenderness on the anteromedial and anterolateral surfaces of the knee. 
In sixteen knees swelling was observed, and from six of them from ten to 
forty cubic centimeters of fluid was a.«pirated prior to taking inienmoroent- 

VOU X.V. NO. 1'. .KVnil. J?3S 


















354 


P. A. QUAINTANCE 


made, using a soft-tissue-detail technique. The air is released, the needle 
is withdrawn, and a sterile dre.ssing and an clastic bandage are applied. 

ANATOMY AND MECHANISM OF INJURY TO MENISCI 

The medial meniscus is densely adherent to the capsular and tibial 
collateral ligaments by fibrous strands and is firmly and closely attached to 
the rim of the tibia by the fibrous coronary ligaments. Normally the 
meniscus is only slightly mobile, its anterior horn receding about one- 
eighth of an inch (three-tenths of a centimeter) posteriorly into the joint 
when the leg is flexed be^mnd 20 degrees. The anterior horn has two 
insertions, — one to the tuberosity of the tibia, the other to the capsule of 
the joint through the transverse ligament (Cunningham). This dual in- 
sertion of the anterior horn, the relative lack of mobility of the medial 
meniscus, and the wider range of circular, gliding motion of the medial 
tuberosity of the tibia on the medial condyle of the femur predispose 
the medial meniscus to disruption and tear when the flexed knee is under 
stress. 

The lateral meniscus, although firmly attached to the capsular liga- 
ment, is very loosely adherent by areolar tissue to the fibular collateral 
ligament. This meniscus is more mobile, and the range of movement of 
the lateral tuberosity of the tibia on the lateral condyle of the femur is less. 
Hence, the lateral meniscus is less subject to stress and is infrequently 
injured. 

In the cadaver *, with the coronary ligaments of the knee intact, 
both menisci are observed to recede fully one-eighth of an inch (three- 
tenths of a centimeter) posteriorly into the joint during flexion and to 
resume their normal position and convex contour during extension. 
When the coronary ligaments are severed anteriorly, recession of the 
menisci during flexion increases to as much as three-eighths of an inch 
(one centimeter). On extension, the menisci fail to resume their normal 
position and contour and are impinged between the femoral condyles and 
the tibial tuberosities. Full extension of the leg is not possible. Rupture 
of the coronary ligaments, therefore, predisposes to displacement, impinge- 
ment, and bruising of the menisci and limitation of extension or locking 
of the knee. 


ANALYSIS OF CASES 

Clinical and pneumoroentgenographic studies were made on fifty 
patients, — forty-seven males and three females. The right knee was 
involved in thirty-two cases; the left, in eighteen. 

A history of a twist was given by thirty-two patients, twenty-four of 
whom stated that the knee was flexed when the accident occurred. 
teen had a direct blow about the knee. Seven reported that the knee ha 
been forced medially or laterally; in four cases this had been in association 

* Dissections done through the courtes3'- of Dr. Paul McICibben, Professor of Anat 
omy, University of Southern California Medical School. 

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PNEUMOHOENTGENOGHAPHY OF THE KNEE JOINT 


357 


displacement was found in a knee in which fracture of a meniscus had 
been diagnosed. The percentage of correct diagnoses of displacement of 
the meniscus, as verified by arthrotomy, was 91. 

In five patients in ivhom both fracture and displacement of a meniscus 
were diagnosed by pneumoroentgenography, the diagnosis was proved 
by arthrotomy, making the percentage of correct diagnoses of fracture- 
displacement of the meniscus 100. 

Of the eight patients in whom loose bodies were diagnosed by pneu- 
moroentgenography, three submitted to operation and the diagnosis was 
proved. In one of these patients plain x-rays prior to pneumoroentgen- 
ography had failed to demonstrate a loose body. 

A pedunculated body, which the pneumoroentgenogram had failed to 
demonstrate, was found at operation in another patient. 

Baker’s cysts (single, unilocular, multilocular, and multiple) were 
demonstrated in four patients. 

Hypertrophic arthritic changes were present in the x-rays of eight 
patients. 

Fractures of the distal end of the femur were observed in two patients 
and fractures of the proximal end of the tibia in five. 

In six patients no pathology in either bony or soft tissues was 
demonstrated. 



Fig. 2-.\ 


^Cn.'^o 17. G. G.. March -I, 1932. 
Xoto absence of the shadow of the 
later.il meniscus fnun its usual ixisi- 
lion. Note also that the lateral and 
medial joint spaces are of equal 
width. 



Fig. 2-H 


_Ca--e 17. G. G., .March 1. 1932. 
Note abnipt bnaik in continuity and 
upward di-pla?im<nt of tin- latent! 
meiii.-cu-, fractuiT di feet in the l.-it/ nil 
condyle, and narrowini: of t!i" latorrd 
tibiofemonil joint -pace. 


VOL. x.\, NO. C. . 


.^riUL 103S 





356 


P. A. QUAINTANCE 




Fig. 1-A 


Fig. 1-B 


Case 9. A. G. H., July 1, 1931. 
The shadow of the medial meniscus 
(anteroposterior view) is normal in 
position and appearance. 


genograms. There was limitation 


Case 9. A. G. H., July 1, 1931. 
The hypertrophied retropatellar fat pad 
(lateral view) projects into the inter- 
condylar notch even when the joint is 
distended. It also is seen quite clearly 
in Fig. 1-A. 


of extension in twenty-four patients and of flexion in eighteen. Instability 
at the knee was found in six cases, resulting from fracture of the lateral 
tuberosity of the tibia in two cases, avulsion fracture of the condyle of the 
femur in two, and injury to the cruciate ligaments in two. There were 
findings indicating sprain of the tibial collateral ligament in eleven pa- 
tients and of the fibular collateral ligament in two. 

In two patients solitary loose bodies were palpated about the knee. 


PNEUMOROENTGENOGRAPHIC AND OPERATIVE FINDINGS 

Of the fifty knees of which pneumoroentgenograms were taken, 
twenty-four, or 48 per cent,, were subjected to arthrotomy. As shown in 
Table I, fracture of a meniscus (medial in eleven, lateral in two) was 
diagnosed in thirteen patients, only ten of whom came to operation. 
Diagnosis of a fractured meniscus was confirmed in all ten. Fracture of a 
meniscus was found in four additional knees in which it had not been 
demonstrated by the pneumoroentgenograms. In one of these, however, 
displacement had been diagnosed. Therefore, the percentage of correct 
diagnoses of fracture of the meniscus proved by arthrotomy was 71. In 
three unoperated patients the diagnosis was not confirmed. 

Displacement of a meniscus (medial in eleven, lateral in four) was 
diagnosed by pneumoroentgenography in fifteen patients, in eleven of whom 
the diagnosis was confirmed by arthrotomy. In an additional patient 


THE JOURNAL OF BONE AND JOINT SURGERY 




CaM' 21. T,. D., June 17, 1032. 
The (hsplaecnu'iit and elevatinn of the 
anteromedial portion of the medial 
menisrn< from the artienlar mar};in of 
tile tihia is shown hy the air spare l>e- 
tween them. Note the normal jn\ta- 
jvisition of the lateral menisrn' and the 
lateral tnhenisity of the tilna. 


CaM' 2S. H. K., .'^ptemher 2S, 1032. 
The air .-pare di'tal to the lateral 
meni'ens indieatc'. m|)Inri‘ of the coro- 
nary huament'. allow me di-iilacemeiit ; 
the motthne ilenote- fatty deceneration 
of eartilage. .\ inrtion of the lonei- 
tiidmal frarture of the meni'-u- found 
on arthrotomy ran he .-(s ii a- a tran-- 
ver-e line near the antenor lioni. 


VOL. X\. NO. e. . 


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358 


P. A. QUAINTANCE 



REPORTS OF ILLUSTRATIVE CASES 

Case 9. A. G. H., male, twenty-eight 
years old, a bookkeeper, on Maj' 13, 1931, 
experienced pain on the anteromedial surface 
of the right knee in squatting after a broad 
jump. For two months he frequently felt 
something “go out of place and snap in after 
a few movements”, during which intervals 
extension was limited. 

E.xamination revealed tenderness ante- 
romedially and slightly limited extension. 

Pneumoroentgenograms (Figs. 1-A and 
1-B), taken on July 1, 1931, after the aspira- 
tion of ten cubic centimeters of thick, amber, 
clear fluid, showed a large, dense triangular 
shadow in tlie anterior intercondylar notch, 
which was interpreted as a hypertrophied fat 
pad. Although the history and phj'sical 
findings were tj'pical of disruption of the 
medial meniscus, such injury could not be 
demonstrated. Ai’tlirotomj’’ was not done. 
Three months later the patient was reported 
to be “getting along well”. 

Diagnosis: Hj'pertrophy of the retropatel- 
lar fat pad. 


Fig. 3-A 

Case 17. Gross longitudinal section 
of injured lateral meniscus, showing site 
of fracture, areas of degeneration, 
vascularization, and replacement by 
fibrous tissue. 


Case 17. G. G., male, forty-five years 
old, a timberman, on April 28, 1931, was 
buried when a trench caved in. Pain, wob- 
bling, recurrent locking, limited flexion in the 
left knee, and disabilit}' were complained of for 


eight months. 

Examination revealed tenderness later- 
ally, slight lateral instability, restriction of flexion, and atroph}’^ of the thigh muscles. 
Climbing stairs caused increased pain, swelling, and recurrence of locking. Plain x-iai'S 
had revealed a small ununited avulsion fracture of the lateral condjde, to which the 
symptoms had been attributed. 

Pneumoroentgenograms (Figs. 2-A and 2-B), taken on March 4, 1932, disclose a 
fracture of the lateral meniscus and an oblique shadow of cartilaginous density in the 
lateral compartment of the joint. The lateral joint space was narrow and the cartilage 
shadow was absent from its usual position. A diagnosis of fracture-dislocation ® ® 

lateral meniscus was made. Two orthopaedic surgeons diagnosed injury to the me. la 

meniscus. * . i„in 

Medial meniscectomy, on March 31, 1932, 1 'evealed insufficient pathology to exp 
the svmptoms. A second incision laterally disclosed a transverse rent in the joint capsu e, 
and fracture, and upward lateral displacement of the anterior horn of the lateral meniscus. 


Lateral meniscectomy also was done. 

Longitudinal section (Fig. 3-A) through the region of the fracture showed clea } 
the abrupt fragmentation and partial degeneration and regeneration of the anterior horn. 
The microscopic picture of the fatty degeneration, vascularization, and pro i era ion o 
connective tissue which followed the injury is shown in Figure 3-B. 

Diagnosis: Fracture-dislocation of the lateral meniscus. 

Case 24. L. D., male, thirty-six years old, a wire worker, while stepping up 
iron horse on April 22, 1932, experienced snapping, pain, and locking of the riga m 
Manipulation under anaesthesia gave no relief. 


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bone and joint surgery 





360 


P. A. QUAINTANCE 



Fig. G-A 

Case 30. L. S., November 22, 1932. 
Fracture defect in the lateral tuberositj" 
and narrowing of the lateral tibiofemo- 
ral joint space are seen in this pneu- 
moroentgenogram taken with the limb 
relaxed. 



Fig. 6-B 

Case 30. L. S., November 22, 1932. 
Note absence of the shadow of the 
lateral meniscus from the joint space. 
Arthrotomy revealed it in position of 
the shadow adjacent to the lateral 
cond 3 de of the femur. 


Examination revealed slight fluctuant swelling and moderate restriction in flexion 
and extension. The cartilage spring test was positive on the medial side. 

The first pneumoroentgenograms, taken on April 22, 1932, after aspiration of twenty 
cubic centimeters of bloodj' fluid, were not diagnostic, although the medial meniscus'was 
mottled near the collateral ligament. A follow-up pneumoroentgenogram (Fig. 4), 
taken on June 17, 1932, showed elevation of the anterior portion and an oblique fracture 
of the medial meniscus at the junction of its middle and anterior portions. 

Arthrotomy on July 22, 1932, disclosed a bucket-handle fracture, contusion, and 
upward displacement of the middle portion of the medial meniscus. 

Diagnosis: Bucket-handle fracture and displacement of the medial meniscus. 


Case 28. B. E., male, twenty-seven years old, an iron worker, twisted his right knee 
on August 8, 1932, while squatting, and had recurring pain and locking for six weeks. 
This knee had been sprained three and two years previously. 

Examination revealed tenderness anterolaterally and posteriorly to the head o le 
fibula, slight limitation of flexion and extension, and a positive cartilage spring test. 

A pneumoroentgenogram (Fig. 5), taken on September 28, 1932, showed tunning, 
mottling, and upward displacement of the lateral meniscus. 

Arthrotomy on October 7, 1932, disclosed a longitudinal fracture, detachment, ana 
upward displacement of the anterior horn, the tip of rvhich remained attached. 
Diagnosis: Fracture-displacement of the anterior horn of the lateral meniscus. 

Case 30. L. S., male, thirty-seven years old, a salesman, on June 7, 1932, 
his left knee under him in falling off a truck. For five and one-half months there was p 

sistent pain laterally with a tendency to “give way”. , „nt„roDOS- 

Examination revealed tenderness and crepitus anterolaterally and s g 


terior instability. 

the journal of bone and joint surgeri 




PNETJMOROENTGENOGRAPHY OF THE KNEE JOINT 


361 


Serial pneumoroentgenograms (Figs. 6-A and 6-B), taken on November 22, 1932, 
showed the lateral atlachmenl of the lateral meniscus to be displaced upward five-eighths 
of an inch and a healed impacted fracture of the lateral tuberosity of the tibia. The 
second pneumoroentgenogram, with pressure exerted laterally, showed widening of tlie 
lateral joint space and upward displacement of the meniscus. 

Arthrotomy on November 29, 1932, disclosed detachment and displacement of tiie 
entire lateral meniscus with the excejDtion of the insertion of its anterior horn. 

Diagnosis: Displacement of the lateral meniscus complicating fracture of the tuberos- 
ity of the tibia. 

SUMMARY 

In this study pneumoroentgenography, using atmospheric air, was 
done on fifty knee joints. 

Hypertrophy of the retropatellar fat pad, indicative of chronic syno- 
vitis or injury, was demonstrated in twenty-one knees. The pad was 
palpably enlarged in only seven patients. 

Baker’s cysts were demonstrated in four knees. 

Fracture of the meniscus was diagnosed by pneumoroentgenographj’- 
in 71 per cent, of the knees in which fractured menisci were found at op- 
eration. Three knees remained unoperated. 

Displacement of a meniscus was diagnosed in 91 per cent, of the knees 
in which a displaced cartilage was found on arthrotomj'. 

Fracture-displacement of a meniscus was verified by arthrotomy in 
100 per cent, of the knees in which this diagnosis was made. 

Loose bodies were diagnosed in eight knees and removed from the 
three knees operated upon. One undemonstrated pedunculated body was 
found at operation. 

Thirty-two knees had suffered a twist; in twenty-four, or 75 per cent., 
the accident had occurred while the knee was flexed. In twenty-four, or 
48 per cent, of the fifty cases, there had Iieen limitation of extension. 

CONCLUSIONS 

Pneumoroentgenography is a simple, harmless, practicable, and val- 
uable aid in the differential diagnosis of injuries and diseases of the soft- 
tissue structures of the knee. 

Its efficiency in demonstrating fracture and di.'^placoment of the 
menisci, as verified by arthrotomj', was 87 per cent, in this series. 


REFERENCES 

H.m.exsweig, Iimx: Loose Body in Knee .loint Demonstrated by Pneurnartiiro-is. 
Surg. Gynec. Olistet., XXXIX, 235, 192-!. 

Beuxsteix, M. a., .\xd .\nEXS, R. A.; Diagno.stie Inflation of the Knee .Inint. A 
Clinical-Radiological Study. Radiologj', VII, 500, 1920. 

C.\TT.\XEO, Filipi'o: Frattura del meniscoarticolareintenio meni.-coraflia. Recidiva con 
bloccaggio irreducible. Meniscectomia. Guaricione. Boll. d. .■'jh'c. Med.-Cliir., 
Ill, 14, 1929. 

CcxxiXGU.^M, D. .1.: Text-Book of .-Vnatomy. Dl. 5. New York, tVdliam WchmI A 
Oi., 191S. 

VOI.. XX. XO. -J. .M’llII. U'.'v'- 



362 


1’. A. QUAINTANCE 


FniEDmcH, H.: Uber die Hoffnschc Sklerose des vorderen Kniegeionkfottkdrpers unci 
ihre Rdntgendingiiose. Fortselir. a. d. Gcb. d. Rontgonstralilen, XXXVI, 64G, 
1927. 

Kleinbekg, Samuel: Injection of 0x3"gen into Joints foi' Diagnosis. Am. .1. Surg., 
XXXV, 256, 1921. 

Pneumartlirosis as a Diagnostic Aid. Report of a Case of Loose 
Internal Semilunar Cartilage. Arch. Surg., VIII, 827, 1924. 

Pulmonaiy Embolism I'^ollowing 0.\ygen Injection of a Knee. 
J. Am. Med. Assn., LXXXIX, 172, 1927. 

Rechtman, a. M.: Pneumartlirosis of the Knee. Surg. Cjmec. Obstet., XLIX, 683, 
1929. 

Simon, H. T.; Hamilton, A. S.; and Farrington, C. L.: Pneumoradiographj' of the 
Knee. A Newer Technic Demonstrating Its Value in the Diagnosis of Semilunar 
Cartilage Injuiy. Radiolog.y, XXVII, 533, 1936. 


the journal of bone a.nd 


joint surgery 



POSTERIOR HERNIA OF THE KNEE JOINT 


A Cause of Internal Derangement of the Knee * 

BY G. E. HAGGART, M.D., BOSTON, MASSACHUSETTS 
From the Department of the Bone and Joint Surgery, The Lahey Clinic 

The object of this paper is to direct attention to the occurrence of 
sjniovial cysts in the popliteal space, and in particular to one t3’-pe of C3’^st 
which at operation is found to be a posterior hernia of the knee joint. In 
the presence of such pathology the patient’s symptoms suggest an internal 
derangement of the knee. Hence, with patients who complain of knee- 
joint disability, it is always important to examine the popliteal space for 
the presence of a swelling. This examination is most informative if the 
patient bears weight on the e.xtremity and if the knee is held in a position 
of complete extension. If a C3^stic swelling is noted, the greater part of 
which is distal to the transverse skin crease in this region (Fig. 1 ), then 
posterior hernia of the joint ma3’- be 
the cause of the s3TOptoms. 

In reviewing the literature, the 
first accurate description of an ab- 
normal S3movial swelling in the Jjop- 
liteal space was found in a short clinical 
report, “Chronic Rheumatic Arthritis 
of the Knee Joint”, In' Adams 
in 1840 . Todd also attributed this 
“dropsical condition of the ])opliteal 
bursa” to chronic rheumatic arthritis. 

In the papers jniblishcd 1 ) 3 ' Gruljcr, 
beginning in 1845 , a comijlete stud3' of 
these cases was ])rescnted. The anat- 
01113' of enlarged Iiursa in tlie iioiiliteal 
sjiace, as well as true iiosterior hernia of 
the knee joint, was described. Billroth, 
in his text book, “ General Surgi.al Path- 
olog3'”, accepted Gruber's conclusions. 

More than thirt3' 3'ears after jiublication of the articles 1 ) 3 ' Adams ;ii i(l 
(KTilier, Bake r, of St. B.'irtliolomew's H ospital. Lo ndon, disciisscfl th e 
formation of s3'novial c ysts in the leg'in relation to ilisease of the kne e 
joint. 1 tiTsiiutlior beheved that the C3'sts were caused b3' O'teo-arthritis 
oTthe kiic^uii oiimion liased on tluMiiuliiigs at dissectioii of aiiitmtated 
e xtreiiiiii es. In two communications. Baker reiiorted his oKen^tioii'- on 
ten jiatieiits with C3'stic swiJIing about the knei-. In three ea<r.<. d,,. 
examination after ani])Utation indicatc-d then' wa> a tru<' jio'terior hernia 

’ Rp;ui lipforc tlio .■\nioriraii .Xcaiiciiiv of ( >rtlmi>a<'<itr .''iircc'oie, I/i- .Viici li--, 
fernia, .lainiarj- tO, lO.'tS, 



Fig. 1 

Case 1. .V localized, weII-deve!oi)ed 
ey.stie swelliiif; of the popliteal space. 


'■<'!. x\. NO Armi. i!os 


364 


G. E. HAGGART 


of the joint. In the remaining cases either infection did not occur, and 
hence ]mtliological examination was not ])ossible, or the cyst was appar- 
ently an enlargement of one of the joint bursae. As a result of the.se case 
reports, any cystic swelling about the knee with a cellular lining similar to 
that of synovial membrane is often referred to in the English literature as 
a Baker’s cyst. 

Posterior hernia of the knee joint or hyperplasia of an adjacent 
bursa is the cause of a synovial cyst in the popliteal space. From the 
clinical standpoint, the e.ssential difference between the two conditions 
is that, although an enlarged bursa may communicate with the joint, a 
posterior hernia always exhibits this relationship and is the cause of 



Fig. 2 


Normal anatomy of the popliteal space. Posterior her- 
nia of the knee joint usuallj’- arises below the oblique 
popliteal ligament of the joint capsule and just medial to 
the mid-line, as indicated. 


symptoms characteris- 
tic of an internal de- 
rangement of the knee. 
This clinical syndrome 
is not now widely rec- 
ognized and hence the 
present series of cases 
is reported. 

In consideration 
of tlie anatomy of the 
popliteal space (Fig. 
2) and the distance of 
the joint capsule from 
the skin surface, it is 
reasonable to assume 
that in the early stages 
herniation would not 
cause undue symptoms, 
nor would it be pos- 
sible to detect clini- 
cally. That is par- 
ticularly true because 
of the subcutaneous 
fat pad which overlies 
this space and from 
which, incidentally, it 
is often difficult to dif- 
ferentiate a true pos- 
terior hernia of the 
joint. Gradually in- 
creasing in size, the 
sac dissects its way 
through the soft fatty 


tissue of the popliteal space, in the line of least resistance, and finally lies 
between the two heads of the gastrocnemius muscle. With further in- 


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POSTERIOR HERNIA OP THE KNEE JOINT 


365 



Fig. 3-A 

Diagrammatic drawing showing location of bursae about the posterior knee region. 



Fig. 3-B 

Diagrammatic drawing illustrating the anatomical relationship of the semimem- 
branosus bursa which mo.^t frequently communicates with the Knee joint. 

crease in size, the sae then extend.^ down tiie lep under tlie deep fa.seia, as a 
rule more on the me.sial than on the lateral aspect of tlie ealf. In tliree 
patients the distal end of the sac reached the mid-calf region. 

Of the twelve Inir.sae tiround the knee joint, two are jKxterior (Fig. 
3-.\) and arc found Ix'tween each head of origin of the ga.strocnemins mu-cle 

VOI.. XX. XO. 2. . 


.\rnii. toss 





3GG 


G. E. IIAGGART 



THE JOURN’M. OF HONE ANT) JOINT SI'UGERV 


POSTERIOR HERNIA OF THE KNEE JOINT 367 



'<'U NX, Nl) .\rnil. I'l- 


368 


G. E. HAGGART 


and the joint capsule. 
They may communi- 
cate with the knee 
joint, particularly that 
bursa beneath the in- 
ner head of the gas- 
trocnemius ^vhich sends 
a prolongation between 
thi.s muscle and the 
semimembranosus, and 
which is termed the 
semimembranosusbursa 
(Fig. 3-B). One pa- 
tient was operated on 
for enlargement of this 
bursa, but the swell- 
ing was definitely lo- 
cated at the inner side 
of the popliteal space, 
and the dissection at 
operation clearly re- 
vealed the point of 
origin from beneath 
the medial head of the 
gastrocnemius muscle. 
A definite communi- 
cation with the joint 
was not demonstrated 
in this case. 

In eight patients 
the hernial sac com- 
municated with the 
knee joint by a short 
pedicle which averaged one centimeter in length, with walls of quite 
dense connective tissue. The opening in the posterior capsule was 
usually below the oblique popliteal ligament and slightly medial to the 
mid-line. The distal wall of the larger sacs was quite thin and firm y 
adherent to the tendon fibers of the gastrocnemius muscle. 

On histological examination, the lining of the hernial sac and of t m 
enlarged bursa was found to be a true mesothelium (Figs. 4-A and 4- 
in every way similar to the lining of the knee joint. In all of the speci 
mens removed there was acute and chronic inflammation of the prous 
lining, together with a moderate to marked round-cell infiltration in le 
subserous layers. The outer wall of the sac, adjacent to the site of origin, 
was composed of relatively dense fibrous tissue similar to the capsu e o 
the knee joint, while the more distal portion was a fine connective tissue 

THE JOURNAL OF BONE AND JOINT SOBOERV 



(.'Exposure of the hernial sac following division of the 
deep fascia and preliminary dissection. Note the adhe- 
sions to the gastrocnemius. 




POSTERIOR HERNIA OF THE KNEE JOINT 


369 


quite friable and easily 
ruptured. 

The most difficult 
differential diagnosis in 
these cases is to dis- 
tinguish between a true 
posterior herniation of 
the joint or hyper- 
plastic bursitis and a 
lipoma in the popliteal 
space or the usual fat 
pad that is present. 

The majority of true 
herniae in this region 
var3'’ somewhat in size 
and likewise give rise 
to a var3dng degree of 
subjective symptoms. 

Furthermore, the pop- 
liteal swelling due to 
posterior joint hernia 
is in greater part distal 
to the transverse skin 
crease of this region. 

In obese patients, the 
deposit of fat in tlie 
popliteal space may be 
quite pronounced and 
not only has the ap- 
pearance of a cj'^stic 
swelling, but on palpa- Pig. g 

tion suggests it. In Tlic s.^c has been di.'sseefed free e.veept for tlie pedicle 
two patients such a "hicli com muni rat as witli tlic knee joint. Note the cut 
^ ‘ " surface of the castrocnemius from which the sac wa.s cut. 

fat pad was found at 

operation and in one instance proved to he a definite lijmma. Inei- 
dentallj^, it is of interest to note that following the removal of tliis fat 
tissue the swelling of the lower leg and foot, which was previously 
present, entirelj' disapjteared. 

One patient with what proved to be a fibrosarcoma of the jiopiiteal 
sjtace was originalh' considered as a po.-^sible member of this group of cases, 
but, on palpation, tlie .swelling was definiteh’ hard and tender, in contrast 
to the cj'stic cliaracter and relativelj' paiidess tumor of tlie lierni:il sac. 
Ancurj’sm of the jmpliteal arterv, so frequent h’ noted in earlier rc])urts. 
is not now often encountered. 

At operation, a mid-line incision is made over the pojtliteal .space and 
tlie site of tlie swelling. Tlie lower end of the incision i< directed toward 

VOI.. XX. XO. AI’IUI. 103s 





370 


G. E. HAGGAHT 


tlic medial or lateral side, depending on 
the locatio]! of the sac. Followiiig divi- 
sion of the deep fascia, blunt dissection 
reveals tlie fibroserous wall of the sac 
(Fig. 5) which is then freed by sharp 
di.ssection, beginning at the more dis- 
tal portion. It is always necessary to 
excise a part of the tendinous fibers of 
the gastrocnemius muscle (Fig. 6), be- 
cause the wall of the hernial sac is so 
adherent that attempting to dissect it 
free results in rupture of the wall. 

The popliteal nerve and, in the 
deep di.ssections of this space, the 
popliteal vessels are displaced to the 
lateral side of the leg to permit de- 
livery of the sac, identification of its 
pedicle, and the point of communication with the joint space (Figs. 5 and 
6). Once the sac is entirely free (Fig. 7), the pedicle is clamped and cut. 
The stump is then inverted into the joint space, and the foramen in the 
capsule is closed with heavy silk mattress sutures (Fig. 8). Tight closure 
of the foramen in the knee-joint capsule is an important step in preventing 
recurrence of the hernia.* 

The wound is sutured in layers, special care being taken to appro.xi- 
mate the edges of the deep fascia. A posterior plaster splint (Fig. 9) is 
then applied from the gluteal fold to the ankle, with the knee joint in full 
extension. This splint is worn for ten days to prevent scar formation, 
due to healing of the wound, from occurring with the knee in the flexed 
position. During this interval, the patient actively contracts the quadri- 
ceps muscle repeatedly. 

During the immediately postoperative period, the knee is distended 
with fluid, sometimes to a marked extent, a reaction similar to that which 
occurs following removal of a meniscus. This fluid is gradually absorbed, 
or, if it persists, can be aspirated. It is believed that this degree of reac- 
tion is chiefly the result of a disturbance of the dynamics of the fluid in the 
knee joint. 

After the splint is discarded, more active muscle exercise is instituted, 
again with particular attention to the function of the quadriceps muscle. 
Early weight-bearing with crutches is encouraged. 

During the past four years twelve patients have submitted to opera- 
tion for cystic swelling of the popliteal space. In nine knees a posterior 
hernia of the joint was demonstrated. In one case the cystic swelling was 
caused by enlargement of the semimembranosus bursa. In another case 
the swelling was a lipoma, and in the remaining patient there was a diffuse 

* Geoffrey Jefferson observed recurrence of tJie cystic s«-eIJing in a child, six years 
old, whom he saw two months after operation elsewhere. 

THE JOURNAL OF BONE AND JOINT SURGLU1 



Fig. 7 

Hernial sac removed in Case 9. 




POSTERIOR HERNIA OF THE KNEE JOINT 


371 


swelling over the popliteal 
region, due to hyperplasia 
of the subcutaneous fat 
pad. The average dura- 
tion of symptoms in this 
group of patients was four 
years: the longest period 
was ten years; the short- 
est, .six months. Eight of 
the patients were female 
and four were male. The 
youngest was a girl of 
ten; the oldest, a man of 
.sixty-two years. Bilat- 
eral posterior hernia or 
enlarged bursa of the 
knee jointwas notobsen’ed. 

All of the patients 
in this group sought relief 
for generalized aching, 
and at times severe, sharp, 

“binding” pains in the 
knee joint, occasionally 
associated with intermit- 
tent effusion into the 
joint ca^^ty. Ten patients described recurrent swelling of the lower leg 
and foot. In the course of observation in three cases it was found that, 
when the effusion into the knee joint was marked, the swelling in the 



Fkj. 9 


.\ftor tlio oiM'r.itivp wound i< a po-terior pL-i'-tf.- ^p!inl. rxii 'iiiiitc from 

tlio glutc.nl fold to tlip ;ink!o, i- «itfi Iho knrx* joint in full < \to!o;o:i. 

'oi. xx, x() o .\ruli. irc%\ 



Fig. S 


The pedicle of the liernial sac is clamped and cut. 
With sufficient tissue in the stump, it is tlion inverted 
into the joint space, and the foramen in the capsule is 
closed with silk mattress sutures. 





Fig. 15 

Case 5. Preoperative .spine-marker roentgenogram, with patient in wedging jacket. 


THE JOUnXAL OF nON’E AXD JOIXT SURGERY 



POSTERIOR HERNIA OF THE KNEE JOINT 


373 


may be suspected when a cystic swelling is found in the popliteal space, 
particularly if located in the mid-line and, in greater part, distal to the 
skin-flexion crease in this region. 

Clinically, the chief symptoms vary from aching discomfort to severe, 
binding pain in the knee region, often associated with intermittent effusion 
into the knee joint. There is a moderate to marked degree of disabilit}^ 
The hernial sac communicates with the knee joint usually by a 
pedicle, one to two centimeters in length, arising either above or below 
the oblique popliteal hgament. The sac may occasionally dissect its wa}*^ 
distally to the mid-calf region, lying on top of the gastrocnemius muscle 
and beneath the deep fascia. 

On histological examination, the lining of the hernial sac is found to 
be a true mesothelium which cannot be distinguished from the synovial 
membrane of the knee joint. There is acute and chronic inflammation of 
the serosa, as well as round-cell infiltration of the subserous laj’-ers. 

BIBLIOGRAPHY 

Adams, Robeht: Chronic Rheumatic Arthritis of the Knee Joint. Dublin J. Med. 
Science, XVII, 520, 1840. 

Baker, W. M.: On the Formation of Synovial Cysts in the Leg in Connection with 
Disease of the Knee Joint. St. Bartholomew’s Hospital Reports, XIII, 245, 1877. 

The Formation of Abnormal Sjmovial Cysts in Connection witii 
the Joints. St. Bartholomew’s Hospital Reports, XXI, 177, 1SS5. 

Billroth, Theodor: General Surgical Patholog>' and Therapeutics, in Fifty Lectures. 
A Te.\t-Book for Students and Pliysicians. Translated by C. E. Hackley. p. 498. 
New York, D. Appleton and Co., 1874. 

Craven-er, E. K.: Hernia of the Knee Joint (Baker’s Cyst). J. Bone and Joint Surg., 

XIV, 18G, Jan. 1932. 

Fullerton, Andrew: The Surgical Anatomy of the .Synovial Membrane of the Knee- 
.loint. British J. Surg., IV, 191, 1916-1917. 

Gruber, Wenzel: fiber die Ausstulpungen der .Synovialkapsel des Kniegelenke.=, und 
iiber die chirurgische Wichtigkeit der Communication derselben mit einigcn benach- 
barten Schleimbeuteln. Vierteljahrschr. f. d. prakt. Hcilkunde, II, 95, 1845. 

Hygrom der Bursa mucosa gcnuali.s rctro-condyloidca inferna s. 
.semimembranoso-gastrocnemialis. Ocstcrrcichischc Zt.';rhr. f. prakt. Hcilkunde, 

XV, 961, 1869. 

Hygrom von enormer Gros.=c an der Bursa genu mucosa rctro-con- 
dyloidca interna. Virchows Arch. f. path. Anat. u. Pliy.siol., XCIX, 489, 1SS5. 
Hawke.s, Forbes: Inflammation of the Bur.sa Gastrocnenno-.Scmimcinbranosa, witli a 
Report of Four Cases of Enlargement and Distention of Tliis Bur.-a Treated by 
E.vcision. Ann. Surg., XXX, 61, 1899. 

Jefferson, Geoffrey: Bilateral Baker’s Cyst.c — Recurrence after 0|X‘r.ition. Proc. 

Roy. Soc. Med. (Sect, for Study of Disc.ase in Children), XIII, 162, 1919-1920. 
McGregor, A. L. : A Sjmopsis of .8urgical ,\natorny. likl. 3, p. 251. Baltimore, 
William Wood and Co., 1936. 

Norton, A. T.: Gangliar Di.^casc of .Toints. British Med. .1., II, 413, 1,881. 

Peoiiam, j. C., Jr.: Five Cases of Intnipoplitcal Bursitis. Providence Misl. .1.. IV, 10, 
1903. 

.SiiEiLD, A. M.: Treatment by Evcision of Bursal Cy.-ts in Connection with the Knee- 
Joint. Clin. .L, XI, 37L 1897-1898. 

Todd: Quoteil by Gruber. 


VOL. NX. NO. AFUII. 193S 



372 


G. E, HAGGART 


popliteal space became much less pronounced. In one instance the pop- 
liteal swelling entirely disappeared, apparently the result of a sudden 
discharge of the contents of the hernial sac into the knee-joint cavity. 
One other patient said that when he liad first noted something the matter 
with his knee it apiDarently contained fluid. At a somewhat later date 
this suddenly disappeared and the swelling in the popliteal space then ap- 
peared, In three instances tlie fluid in tlie knee joint remained for a period 
of time and was eventuall}'’ absorbed, and then the cycle was repeated. 

The frequency with which this interchange of synovial fluid between 
the hernial sac and the knee joint occurs apparently depends on the 
particular mechanics of the opening communicating between the two re- 
gions, — that is, if the pedicle of the liernial sac becomes twisted or crushed 
uiDon itself, or unduly thickened so that the lumen is blocked, then the 
popliteal swelling is consistently present. If the lumen of the pedicle is 
patent, fluid moves from one space into the other, depending on the 
activities of the individual, and especially appears to be affected by long 
periods of standing with the knee joint fully extended. This latter posi- 
tion tends to compress the herziial sac and to force the contained fluid into 
the knee joint. Izi ez^eiy case in wJiich opei-atioji Avas performed, how- 
ever, the foramen between the joint caAUty and the hernial sac was patent, 
although in some instances thei’c was marked fibrosis of the pedicle of the 
sac Avith a narroAv lumen. Four patients had never noticed fluid in the 
knee joint proper. On the other hand, Avith tAVO exceptions, none of the 
group had observed a SAvelling in the popliteal spaee. 

The roentgenograms of these knee joints consistently did not reA^eal 
any abnormality except in the older patients in AAdiom some slight degen- 
erative changes Avere found. The latter probably had in some measure 
been increased because of the irritatiAm reaction set up by the interchange 
of fluid between the hernial sac and the joint, but in no instance were these 
changes marked. 

Seven patients obtained relatively rapid increase of motion in the 
knee, so that AAUthin three Aveeks after operation normal flexion and ex- 
tension without SAvelling of the joint Avere present, as well as adequate 
function of the muscles of the loAver extremity. In two instances the 
interval was longer, — one patient required four Aveeks and the other six 
weeks to obtain full motion. This delay Avas due to the long duration of 
symptoms and to the seriously compromised function of the quadriceps 
muscle before operation, together with the fact that neither of these tAVO 
individuals was very robust or active. 

The longest follow-up in this series is four years; the shortest, eight 
months. In each of the patients the extremity is now normal and 
measures the same as the non-operated leg. None of the patients has 
experienced any further symptoms in the knee joint. 

SUMMARY 

In the presence of posterior hernia of the knee joint the patients 
symptoms suggest an internal derangement of the knee. This condition 

THE JOURNAL OF BONE AND JOINT SORGERV 



A BCD 

Fig. 1 

A: Outline of the roentgenograms of a child’s knee in flexion and in extension. 

B: Outline of a regular wedge osteotomy showing the shortening that occurs in 
correction. 

C: Outline of an osteotomy with the pivot at the approximate center of motion of the 
knee, showing that in the corrected position the original length is maintained. The 
upper diagram also shows that the posteriorly slanted section of the tibia is a function of 
a small radius of hinged knee-joint motion. 

D; Outline of an anterior wedge osteotomy showing that the length of tlie corrected 
log is longer than the original extremity. 



A diagram visiializing the ef- 
fect of tlic location of the pivot 
of an o--tcotoiny in relation to the 
length of the corrected extreniily. 



I'lG. 3 

Outline of a flange 
o-H'otomy. 



I'lo. -t 

n 

U’lth t}if‘ frncriM-rit' 
Jii partinl rnrr^-rt h'Tj. 


VOL. NO APUIL 




FLANGE OSTEOTOMY FOR THE CORRECTION OF KNEES 
ANKYLOSED IN FLEXION 

BY HENRY BRIGGS, M.D., NEWARK, NEW JERSEY 
From the New Jcrseij Orthopaedic Hospital and Dispensary 

By osteotomy and a wedging turnbuekle jilastcr encasement, a knee 
ankylosed in flexion can be straightened without injury to tlie circulation 
or to the innervation of the distal fragment. The truth of this proposition 
has been demonstrated by AA^hitman. It is tlic author’s purpose to show 
that, by the location of tlic pivot of motion, such an extremity may be 
shortened, or its original length may be maintained or increased by 
osteotomy, and to present anewtechniqueof correction by flange osteotomy. 

In order to sliow the effect of the location of the ])ivot on the length 
of the straightened extremity, tracings of lateral roentgenograms of a 
normal child’s knee in right-angled flexion and in extension have been 
made. By using the tracing of the knee in I'ight-angled flexion as a model, 
various corrections have been made and the resulting length has been com- 
pared with that of the knee in extension. 

Figure 1 demonstrates that the ordinary wedge osteotomy shortens 
the extremity in comparison with its original length, that a wedge osteotomy 
with a iiivot at the approximate center of motion of a knee maintains the 
original length, and that an anterior ivedgc osteotomy may lengthen the 
extremity. 

The mechanism of those relationships can be visualized by a study ol 
Figure 2. It is obvious by counting the squares that a pivot located at 
0 on the line OA gives the greatest shortening, and that the further toward 
A on the line OA the pivot is moved, the longer becomes the straightened 
extremity. Furthermore, an extremity straightened with a pivot on one 
point on the line X will be equal in length to an extremity straightened 
with a pivot on any other point on the line A'. The same can be said for 
lines Y and Z. Thus, a supracondylar osteotomy could be performed at 
N with the same effect in length as if it were performed at M. In other 
words, a study of this diagram shows that the length of the straightened 
extremity will be equal to the long axis of the proximal fragment plus the 
long axis of the distal fragment, both axes being projected from the actual 
pivotal point of the osteotomy. 

A flange osteotomy is simply an anterior wedge osteotomy constructed 
with a flange to aid in preventing posterior displacement of the distal 
fragment in the process of gradual extension. Figure 3 shows the con- 
struction of an anterior wedge AOB ivith 0 as the pivot and a line OA 
perpendicular to the long axis of the tibia and the line OB perpendiculai , 
or slightly less than perpendicular, to the long axis of the femur, depending 
on -whether the desire is to have the corrected extremity straight o) 

074 the JOURN'AL of bone AXI 3 JOINT suitOKn-i 





'OU XX, NO. 





376 


HENRY BRIGGS 


slightly flexed. Then a flange is outlined so that the angle OXY is ap- 
proximately a right angle and the line XY is the shortest distance from X 
to the posterior border of the knee. This short line XY should be chosen 
in order to minimize posterioi- projection of the corners N and M (Fig. 4) 
in the extended position. It is apparent that this flange tends to prevent 
a backward luxation of the distal fragment in the process of gradual 
extension. When the flexion deformity is not too groat, an exfcracapsular 
supracondylar flange osteotomy may be performed without greatly 
offsetting the long axis of the femur on the tibia. The supracondylar 
section is technically easy to perform and avoids the lower femoral 
epiphysis. The following ca.se is illustrative. 

CASE REPORT 

B. E., a wliite girl, twelve years of age, was admitted to the liospital on October 11, 
1934, complaining of a deformity of the left knee. The trouble had started eight years 
previouslj' when the patient had been treated in a New York hospital for tuberculosis of 
the knee. 

Examination showed the knee ankylosed in flexion and cariying scars from previous 
operations. A diagnosis of old tuberculosis of the knee with flexion deformity was made, 
and an osteotomy was I'ecommended. 

On November 2, 1934, under tourniquet, a lateral incision about four inches long 
was made over the outer aspect of the lower third of the femur. The quadriceps femoris 
and the tensor fasciae latae were retracted and the vastus lateralis was split anterior to 


THE TREATMENT OF SLIPPING OF THE UPPER FEMORAL 
EPIPHYSIS WITH MINIMAL DISPLACEMENT * 


BY PHILIP D. ■R’lLSON, M.D., KEM' YORK, X. Y. 

The subject of slipping of the upper femoral epiph 3 '^sis is so large that 
the author proposes to confine this paper to a discussion of the following 
points: 

1. The treatment of early stages of slipping. 

2. The effect of operative fusion of the upper femoral epiphJ^sis upon 
growth of the lower extremity. 

THE TREATMENT OF THE EARLY STAGES OF SLIPPING 

It is trite to remark that the be.st time to treat a disease is from the 
beginning, but this statement is so true of slipping of the upper femoral 
epiphy.sis that it needs to be emphasized. The earliest stages of slijijiing 
almost always give rise to symptoms which, if the phj'sician is alert, can 
be recognized and will lead to the correct diagno.sis. Given a patient be- 
tween the ages of ten and .sixteen years, complaining of intermittent jiain 
and .stiffness in the knee or thigh with at times a noticeable limji, one 
should consider .slipping of the epiphj'sis as one of the first possibilities. 
Nor should one be led astraj'' by the frequent localization of pain at the 
inner side of the knee into making only a local examination of that part; 
a thorough examination of the entire extremitj' should be made. Guard- 
ing or limitation of motions of internal rotation and of abduction of the hip 
are characteristic of epiphyseal slipping and can be ilemonstraled almost 
invariabljL Shortening of slight amount ina}’’ or maj' not be iiresent, init 
it is not essential for a diagnosis. Since approximatelj' 70 per cent, of the 
patients are overweight, the association of these .'^j'lnjitoms with obesitj" in 
childhood should especiallj' lead one to suspect the condition. 

Suspicion of a pathological lesion of the hip will lead to a roentgeno- 
graphic examination, and an accurate diagnosis can then be made. 'J'he 
irregular rarefaction of the metaphj’seal zone of the neck in immediate 
contact with the ejiijilij'seal cartilage, giving a characteristic apiiearance 
of widening of the epijihj'scal line, is alwa^-s evident, especialh' upon coin- 
inirison with the normal hij). This mar' or mar' not be associated rvith 
evidence of displacement as shorvn br' a change in the relationshii) of the 
eiiiphr'sis to the neck. 

The diagnosis of slijiiiing of the ujiper femoral e])ii)hr'sis at ;in eariv 
stage, rvhen the dis])lacement is still minimal and not sufficient to (-.•ui'-e 
anr' i)ermanent functional imjiairment, ijermit-; an entirelv different tr'i)>' 
of treatment from that rvhich is necesvarr' when serion< deformitv i- 
present. An ojicration to realign the ejiijjhr'si-^ mar' be avoided, and the 

" Rcaii at tlic .\nnual Moctiiic nf ttic .\nirricaii .\t-aiii-iiiy of ciiii- 

L>s Califonii.a, .laiiuary 'Jt'. HKts. 

'<'1. w. xc) Aruii. lOK 



378 


HENRY BRIGGS 


the tensor fasciae latae, exiiosing the shaft of tlie femur. The periosteum was incised 
and elevated. Tlie femoral shaft was drilled twice transversely with a quarter-inch 
drill, making drill holes one-half an inch apart and parallel to the long axis of the femur 
in the anterior half of the shaft (Fig. 3, points 0 and X). These drill holes were joined 
with an osteotome. With a saw, on the dorsal surface of the femur slanted from above 
downwai'd, a wedgelike cut was made to join the superior drill hole (Fig. 3, line BO). 
With a Gigli saw passed beneath the femur, a .section was made transverselj’’ to join the 
distal di'ill hole (Fig. 3, line FA'). With an o.steotome, an anterior wedge (Fig. 3, line 
AOB) was removed, using the superior drill hole as the axis until full correction of the 
deformity was obtained. The wound was sutured in ln 3 ’ers. A plaster spica was applied 
with the flexion corrected to allow a strong pulsation of the popliteal artery". 

On November 10, 1934, hinges were inserted into the cast and further correction was 
started. On November 17, the deformitj' had been completelj' overcome, and, on 
November 24, the turnbuckles were I'emoved and plaster was applied to maintain the 
corrected position. One month later the fragments felt strongl}'^ united, but splintage 
was maintained until March 27, when walking without support was instituted. 

Final roentgenograms (Fig. 7) were made on Februarj'- 10, 1937, which show the 
end result of this operative procedure. 

REFERENCE 

WnmuN, Armitage: A New Method of Osteotomj’ for the Correction of Long Standing 
Bony Deformity at the Knee. J. Bone and Joint Surg., XVI, 155, Jan. 1934. 


THE JOURNAI. OF BONE AND 


JOINT SURGEIl'i 






380 


P. D. WILSON 


outlook for complete functional restoration is infinitely better. Since the 
physician who is usually first consulted by the patient is the general prac- 
titioner, and since so much depends upon his recognizing the condition in 
its earliest stage, we orthojDaedic surgeons have a duty to see that he is 
made familiar with the pathological and clinical appearances of the disease 
and that adequate instruction on this subject is given to the students in 
our medical schools. 

It is inaccurate to descrilie these cases of early slipping as “preslip- 
ping” or “without displacement”. Real slipping occurs as soon as the 
epiphysis is loosened, and without .slipping it is doubtful if there would be 
any .symiatoms. As was stated bj'^ Milch, the first step in the mechanism 
of displacement is anteversion of the neck in relation to the epiphysis, 
which jDroduces the characterislic fixed external rotation of the extremity. 
Only later does the upward displacement of the neck take place, resulting 
in the typical deformity with the capital epiphysis bung posteriorly and 
inferiorly. 

The difference, then, between a case of early slipping and one of severe 
displacement is merely the degree of deformity. Any attempt, therefore, 
to fix a boundaiy between the displacement that is of no serious functional 
significance and that which is must be purely arbitrary and approximate. 
In making a decision one should be guided, not only by the roentgeno- 
graphic examination, but also by the clinical evidence. More information 
as to the amount of displacement is usually to be obtained from the lateral 
roentgenogram than from the films made in the anteroposterior plane. 
When in the anterior view the upper border of the epiphysis appears well 
above the upper surface of the neck and in the lateral view the epiphysis 
has not displaced posteriorly more than one-third of the diameter of the 
neck, then, the author believes, the deformity may be safely accepted. 

The writer has followed a number of jDatients who showed this amount 
of displacement and has seen them recover normal function with the 
exception of a slight loss of internal rotation. Important information m 
respect to the amount of deformity can also be obtained from the clinical 
examination. When there is free abduction and not more than 10 degrees 
of fixed external rotation of the hip, no disability will result provided that 
any further slipping is prevented. 

Having made a diagnosis of slipping of the upper femoral epiphysis, 
and having determined that the amount of displacement does not exceed 
the above limits, what is the best plan of treatment? In previous com- 
munications by Waldenstrom, Ferguson and Howorth, and the authoi, 
it was pointed out that sound healing was not obtained until the epiphysis 
was fused to the neck and the epiphyseal cartilage became obliteiatcc . 
The method of treatment which will most surely and rapidly accomp is i 
this result, without risk of further displacement, is, therefore, the one o 
be preferred. The writer has made a thorough trial of weight-bearing 
caliper braces and ambulatory plaster spicas as protective devices an las 
rejected them as inefficient and dangerous. He has seen complete is 

THK journal of BONE AND JOINT SUHGER'i 



SLIPPING OF THE TIPPER FEI.IORAL EPIPHYSIS 


381 


placement of the epiphysis occur in patients who were being treated by 
these methods. Recumbent treatment in a plaster spica is open to criti- 
cism on the grounds of uncertainty. It must be continued until epiphyseal 
fusion is obtained, and this may be a year or more. The author has seen 
recurrence of symptoms in a patient eleven months after immobilization 
in plaster was begun. Long-continued fixation is also harmful because 
of the ensuing atrophy. Waldenstrom and Wardle favor the use of con- 
tinuous extension, but the former expects that such treatment may have 
to be prolonged for as much as a year in order to obtain healing. 

There remain to be considered various methods that aim at obtaining 
early fusion of the epiphysis. Jah.ss proposed hammering on the lateral 
aspect of the trochanter to traumatize the epiphysis, followed b}'^ the 
application of a plaster spica, and reported good results from this treat- 
ment. The author distrusts the use of a method whose force cannot be 
accurately controlled, and feels that it is unlike!}' that uniform results can 
be obtained. Ferguson and Howorth advocated drilling through the 
epiphyseal plate and the insertion of small sliver bone grafts. Their 
method requires arthrotomy and seems unnecessarily complicated. 
Multiple drilling through the neck from the trochanter has been done by 
Bazin and others, but this does not seem an entirely easy or hazardle.ss 
procedure, and it does not obtain fixation of the epiphy.sis. 

In a previous communication the writer described an operative re- 
alignment of the displaced upper femoral epiphysis with fixation by the 
Smith-Petersen nail. This procedure requires arthrotomy of the hip and 
is only justifiable in cases with severe displacement. As methods were 
devised for the fixation of fractures of the femoral neck by the insertion of 
nails or pins through the trochanter under roentgenographic control 
without arthrotomy, it was natural to make use of this technique in the 
treatment of early slipping of the upper femoral epiphysis. The first 
patient to be treated by this method was operated upon by the author in 
October 1934, and since that time a total of nine patients have been sub- 
jected to the procedure. It has proved admirable for its purjiose, and 
complete functional restoration has been obtained in those case.s where the 
amount of posterior displacement of the epiphysis did note.xceed the limit 
of acceptable deformity as previously explained. 

The writer employed the Sinith-Petorsen nail as the instrument of 
internal fixation and made use of Wescott's technique for introducing it. 
Reduction was not attempted. Under general anaesthesia an incision 
was made over the lateral aspect of tiie trochanter, and the nail was started 
at a point aliout one inch Ijelow the ridge for the insertion of the vastus 
lateralis. The leg was held by an a.s-istant, with the hip internally ro- 
tated as much as jjossilile, and the nail was driven home at thi> angle ;ind 
to the depth jireviously determined from lue.asiirement of the roentgeiK)- 
grams of the hi]). The direction of the nail was controlled I)y roent- 
gcnograjihic examination in both tlie anteroiio-terior and Intend planes 
dtiring the course of the ojieration. On the whole, the j)rocedure is 

VOL. XX. NO. t. Arnii. iiijs 



382 


P, 1). WILSON 


.simple, ailhongli, hocanso of tlie posterior dis]')]aeemenl of the licacl, tliere 
is more need foi' aeeurafe roenigenograi)hie eoiitrol in tlic lateral plane 
than in the ease of a fraetured femoral neek. 

After elosure of the wound and the a]iplieation of a firm dre.ssing, the 
patient was returned to bed without any external splinting. The post- 
operative discomfort was slight and the patient, was allowed to be up at 
the end of one week. The author does not know how soon the.se patienhs 
may be permitted to bear full weight on their hips and he has erred on the 
side of safety. They were required to walk with crutches and a raised 
shoe on the sound side iint il t he end of eight weeks. After this period full 
aeti^'ifies were permitted, with the exception of rough .sports. 

The use of the nail in the.se ca.se.s .serves two purposes. It fixes the 
epiphy.sis and thus prevents anj^ po.ssibilitj'’ of further displacement; and it 
also penetrates the cartilaginous plate and allows the ingrowth of repara- 
tive elements, thus jU'omoting healing and early fusion of the ejfiphysis. 
Study of the progress of the healing by roe)itgenographic observation 
shows that obliteration of the epiphyseal cartilage is usually obtained in 
from four to six months. Later removal of the nail seems ad'sdsable, 
although there has been no evidence that an}'- irritation was caused by it. 
The writer has made a practice of doing this usually at the end of about 
nine to twelve months. This is a simple operation, not involving a lay-up 
of more than a few days, which, nevertheless, constitutes the chief dis- 
advantage of the method. The simplicity and security of the procedure, 
together with its avoidance of postoperative splinting and its great saving 
of time for the patient, are such positive advantages that they far out- 
weigh this one objection. 

Two points should always be remembered in the treatment of pa- 
tients with early slipping of the upper femoral epiphysis. The first is 
that the patient’s condition should be considered as urgent from the mo- 

TABLE I 

Measurement.s of Shortening of Legs in Patients Whose 
Epiphyses Were Nailed 


Case 

No. 

Name 

Sex 

Age at 
First 

Involvement Operation 
(Vears) 

Preoperative 

Shortening 

{Inches') 

1 

A. M. 

Male 

Unilateral 

12 

Vi 

2 

D. W. 

Female 

Bilateral 

12 

V 

3 • 

W. Y. 

Female 

Unilateral 

12 

0 

4 

G. W. 

Female 

Bilateral 

10^2 

0 

5 

D. F. 

Male 

Unilateral 

16 

Vi 

6 

H. P. 

Male 

Unilateral 

12K2 

V 

7 

J. B. 

Male 

Unilateral 

14^2 

0 

8 

R. F. 

Female 

Unilateral 

12^2 

0 

0 

C. s. 

Male 

Unilateral 

15^2 

3^ 


Shortening 

Post- 

at Last 

operative 

Measurement 

Period 

(Inches) 

(MorUhs) 

Vi 

34 

H 

31 

1 

27 

0 

18 

0 

16 

0 

13 

0 

13 

34 

5 

34 

4 


THE JOURNAL OF RONE AND JOINT SUUGERV 



SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


3S3 


ment that the diagnosis is made or even suspected. The author can recall 
several instances where the physician did not insist upon immediate treat- 
ment and the patients returned home only to be brought back to the hos- 
pital a few days later by ambulance because a slight misstep or fall had 
resulted in a complete separation of the epiphysis. The outlook for the 
patient who is treated in the early slipping stage is so far superior to that 
of one with complete displacement that no risk of the former condition’s 
being converted into the latter should be permitted. Until the epiphj^sis 
is nailed, the only safe place for the patient is in bed with extension to the 
leg, and any delay in instituting such treatment is dangerous. 

The other point is that the possibility of bilateral involvement of the 
hips should be constantly kept in mind. The patient and his parents 
.should be warned to report the slightest suspicious symptoms arising on 
the unaffected side, and, as an extra safeguard, both hips should be in- 
cluded in the roentgenographic examination as often as this is required. 
In this way slipping of the other epiphysis can be recognized and treated 
while still in a favorable stage. 

THE EFFECT OF FUSION OF THE UPPER FEMORAL EPIPHYSIS UPON GROWTH 
OF THE LOWER EXTREMITY 

One of the first questions that arose in connection with the treatment 
of slipping of the upper femoral epiphysis b}-^ the insertion of a nail or pin 
was: “What would be the effect of early fusion of this epiphj\sis upon the 
growth of the extremity?” Although at the time the author was unable 
to answer this question, he .soon satisfied himself that it was largely 
academic, since the review of a series of roentgenograms of patients treated 
in plaster without operation showed that the epiph3'.seal cartilage fused 
carlj'^ in anj’^ case. Subsequent follow-up e.xamination of the patients 
whose hips were nailed was rea.ssuring and showed that serious shortening 
of one extremitj’^ did not develop. The measurements of inequalitj' in 
length prior to operation and at the last follow-up observation in the nine 
patients whose epiphj'ses were nailed are shown in Table I. It will be 
seen that four patients showed no shortening; one had shortening of one- 
quarter of an inch; three, of one-half an inch; and one, of one inch. Of the 
five patients with shortening, three showed the same amount a'< had existed 
before ojieration and onlj' two with legs of ecpial length in the i)eginning 
showed later inequalitj'. Two patients with sligiit ineqnalit\' befon* 
o])eration made good the deficiencj’ and later had legs of ctinal length. 
Tlie greatest amount of sliortening was one inch in one ])atient and thi- 
did not increase in the last eighteen months. 

It is of interest to trv to cxiilain the.se rather siirijrising oi)<ervations. 
Digbjq in his studies of the growth of the long l)ones. gave tlie figures for 
the femur and the tibia shown in Table II. 

While both Gra.v and Picrsol give the time for the clo-ing of the ni)])er 
femoral epiiihj’sis at about eighteen j'cars, Cohii. who-e eoneln-ion' were 
drawn from tlie stnd.v of a series of roentgenogram^, fixed it at aiijiroxi- 


VOI. NX. NO :. .M'KII. IV.-!' 



384 


P. I), WILSON 


TABLE II 

Growth of Bones of Lower Extremitv (Digby) 


Epiphyseal Region 


Amount of Growth Percentage of Growth 


Upper end of femur 5.0 inches 17.2 

Lower end of femur IJ.O incl)c.? 37.8 

Upper end of tibia 7.5 inche.s 25. S 

Lower end of tibia 5. Cinches 19.2 


Total 29,1 inche.s 100.0 


mately fifteen years, and this is probabi}’- the more reliable figure. Since 
this epiphysis contributes approximately 17 per cent, of the total growth 
of the lower extremit 3 '’, and since slipping of the upper femoral epiphysis 
occurs between the ages of ten and sixteen 5 '-ears with an average age of 
about thirteen j’-ears, one is forced to conclude that the absence of serious 
shortening is due either to a precocious closing of the corresponding epiph- 
ysis on the unaffected side or to the fact that most of the growth from 
the upper femoral epiphysis takes place early and diminishes to a small 
amount after the age of twelve j’-ears. While Cohn’s studies support the 
latter hypothesis and this affords an adequate explanation in children be- 
longing to the older age group, it does not seem sufficient in those of from 
ten to twelve years. The author’s OAvn observations show that closure 
of the unaffected epiphysis usually takes place within two years after the 
appearance of slipping, which is frequently considerably in advance of the 
normal time. Precocious closure of this epiphysis lends confirmation to 
the theory that epiphyseal slipping is the result of metabolic disorder. 

Another question that has been raised in connection with early 
closure of the upper femoral epiphysis has to do with the effect of contin- 
ued growth of the epiphysis for the greater trochanter upon the gradual 
reduction of the angle of the femoral neck. It was suggested that the 
trochanteric region of the femur would continue to grow and that with the 
capital epiphysis closed, resulting in a stationary position of the head, a 
gradual ascent of the greater trochanter would take place with the produc- 
tion of a coxa-vara deformity. The writer reviewed a series of late 
roentgenograms in a group of patients upon whom operative replacement 
of the epiphysis and nailing had been performed some time earlier and was 
inclined to agree that there was some confirmation of this theory. Acting 
upon this belief, in 1934 he fused the epiphysis for the greater trochaiitei 
in two patients at the same time that he nailed the capital epiphysis.^ 
(See Cases 1 and 3.) These patients have now been followed thirty-foui 
and twenty-seven months respectively and, while they show no change 
in the angle of the neck with the shaft, neither do any of the other patien s 
in whom nailing of the capital epiphysis alone was done. Therefoie, m 
writer is unable to demonstrate in the period of time that has t lus ar 

THE JOURNAL OF BONE AND JOINT SURGERY' 







386 


P. D. WILSON 




SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


3S7 



Vim. .W. Niv M’ltll. I'l'v 


388 


P. D. WILSON 



Fig. 4 — Case 4. 


SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


389 


elapsed that there is any advantage to the patient in this particular 
procedure. 


CASE REPORTS 

Case 1 (H17-949). A. M., male, aged twelve, was admitted on February 11, 
1935, with a history of a fall four months previouslj', followed by increasing pain in the 
left leg and a limp. Physical examination .showed an obese bo 3 ' of the “Frohlich” tj-pe, 
with slight limitation of abduction and internal rotation of the left hip. There was one- 
half an inch of shortening of the left leg. Koentgenographic examination on Februarj- 
13, 1935, showed widening of the epiphj’seal line, but onlj- slight displacement of the 
femoral head. A diagnosis of slipping of the upper femoral epiphj'sis was made and 
operation was advised. 

On Februarj" 20, 1935, under general anaesthesia, an incision was made over the 
lateral aspect of the greater trochanter, and a Smith-Petersen nail was inserted following 
Wescott’s technique. An epiphj’siodesis of the trochanteric epiphj'sis was also done. 
The patient was kept in bed one month and was then permitted up with a one-inch lift on 
the right shoe and crutches, which he continued to use for four months. He then resumed 
full activities. 

The nail was removed on October 11, 1935, eight months after insertion. When 
seen on December 22, 1937, thirtj'-four months after nailing, the patient had no com- 
plaints or disabilitj'. Examination showed no appreciable limitation of motion of the 
left hip. There was shortening of one-half an inch. The measurements were as follows : 


Left Right 

Length 34 inches 35 inches 

Abduction 45 degrees 35 degrees 

External rotation 60 degrees 40 degrees 

Internal rotation 15 degrees 20 degrees 

Flexion 135 degrees 135 degrees 

Extension Normal Normal 


Case 2 (H19-030). D. W., female, aged twelve, was admitted on Maj' 20, 1935. 
Tlie patient complained of pain in the left hip of five weeks’ duration which began in- 
sidiouslj' and without injurj'. Phj'sical examination showed an overweight girl witli a 
limp on the left side and limitation of internal rotation and of abduction of the left hip. 
There was one-half an inch of shortening of the left leg. Roent genograpliic examination 
showed rarefaction at the epiphj-seal line and slight posterior displacement of tlic femoral 
head. 

On Maj' 22, 1935, an operation was performed under ether anacsthe.sia. The 
epiphj'seal cartilage was drilled in several places, and small sliver bone grafts were in- 
serted in the drill holes. The patient made an uneventful recoverj' and was discharged 
on June 25, 1935. She walked with the aid of crutches until the end of eight weeks and 
then resumed full activities. 

In March 1930, .she began having stiffness and fatigue in the right lower extremity. 
There was a slight limp, but no restriction of motion and no shortening. Roenfgcno- 
graphic examination showed rarefaction along the line of the right capital epiphysis, 
but no demonstrable displacement. The left capit.al epiphj'sis was united. 

She w.as reiidmitted to the hospital and, on March 21, 1930, an ojx“ration on the 
right hip was performed. A Smith-Petersen nail was inserted through a lateral inci-ion 
over the trochanter under roent genograpliic control. The patient was discharged, and 
walked with crutches for five weeks; .“he was (hen permitted full activities. .She wa- re- 
admitted to the hospital aiiproximatelj' one j'ear later, and the nail w.as removed. 

When c.xamined on December 22, 1937, she complainetl of only an ocra-ionrd 
weather pain”, but was eonsciou.sof no disabilitj'. There was one-half an inch of shorten- 
ing of the left lower extremitj'. All motions of Iwth hips were painle.-s and free. Roent- 


voi.. XX. NO. I. .\rnn. is.is 



390 


P. D. -WILSON 







SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


391 


genographic examination showed both capital epiphyses to be fused. The comparative 
measurements were as follows; 


Left Right 

Length 34*4 inches 35 inches 

Abduction 33 degrees 40 degrees 

External rotation 55 degrees 35 degrees 

Internal rotation Normal Normal 

Flexion Normal Normal 

Extension Normal Normal 


C.\SB 3 (H14-917). W. y., female, aged twelve, was admitted on August 12, 
1935. The patient gave an indefinite history of a fall from a swing, followed by pain and 
limp of the left leg of six weeks’ duration. Examination showed an obese girl in good 
physical condition. The left lower extremity was held in a position of external rotation 
and could not be internally rotated to beyond a neutral position. The leg lengtii was 
equal. Other motions of the hip were free. Roentgenograms, taken on August 7, 1935, 
showed slight posterior displacement of the femoral head and widening of the zone of the 
epiphj'seal cartilage. 

On September 11, 1935, an operation, consisting of the insertion of a Smith-Petersen 
nail by Wescott’s method, was performed, and an epiphysiodesis of the trochanteric 
epiphysis was done. The patient was kept in bed for three weeks and was then dis- 
charged on crutclies. Weiglit-bearing was not permitted until the end of three months. 
Roentgenograms on September 14, 1935, and January 30, 1936, showed the nail in good 
position. The nail was extracted on June 24, 1936, nine and one-half months after 
insertion. 

When last examined on December 22, 1937, twenty-seven months after nailing, the 
patient presented no complaint or disabilitj'. There was one inch of shortening of the 
extremity. The range of motion of the operated hip was entirelj" comparable with that 
of the normal hip, and there was normal musculature. The roentgenogram showed both 
capital epiphyses fused. 

Case 4 (H23-249). G. W., female, aged ten years and eight months, was ad- 
mitted on June 1, 1936, complaining of pain in the right hip and lameness of about one 
year’s duration. The onset was gradual without history of injury. Examination 
showed a short, obese girl walking with a marked right-sided limp. The right hip was 
held in fi.xcd c.xternal rotation of 20 degrees and in slight adduction. All motions of the 
hip were limited and guarded. The leg length was equal. The roentgenographic c.x- 
amination showed moderate downward and marked posterior displacement of the capital 
epiphysis. Operative realignment was advised. 

Operation was performed on June 3, 1936. The hij) was exposed by a goblet-shaped 
incision, extending downward and laterally from the anterior superior spine and separat- 
ing in the plane between the tensor fasciae femoris and the s.artorius. The capital 
epiphysis was found lying posteriorly but firmly united to the neck. It was separateti 
with a chisel without injuring the ligamentum teres. The neck was trimmed to fit 
accurately and was then replaced in normal relation to the head. A Smith-Pcter.=en nail 
was driven up through the trochanter, solidly fixing the head. The wound was closed, 
and the patient was returned to bod with light adhe,sive extension to the leg. At the 
end of two weeks the extension was discontinued and active cxercisc.s were .‘-tartc<l, but 
without weight-bearing. The patient wa.s allowe<l up on crutches with a raided sole 
on the opposite shoe. Mobility of the hip was rapidly recovered and the patient w.-e- di— 
charged on July 15, 1936. Full weight-bearing was permitted at the end of three 
inontlis, and she nipidly resumed normal activities. 

She was readmitted to the ho-pital on July 19, 1937, for removal of the nail. .4t 
this time the roentgenographic c.xamin.ation showeti solid fu.sion of the riitht femoral 
epiphy.sis, but widening of the cpiplnveal-cartilngc space in the left hip and evidence of 
beginning slipping. An ojicration was performed on July 21, 1937, under gi iieral anae— 

'■on. xx, xo. c. 


ArniL ie3« 



22 


F. L. BUTTE 


and spine fusion for scoliosis. While in man}'- cases the end results have 
not been as good as could be desired, and while we are continually striving 
to improve the technique, yet we feel that this method of treatment in 
selected cases is entirely worth while and gives more striking permanent 
improvement than any other method at present known to us. The prin- 
ciples discussed in this paper are important factors in securing such results. 

REFERENCES 

Ferguson, A. B.: The Study and Treatment of Scoliosis. Southern Med. J., XXIII, 
116, 1930. 

Hires, 'R. A.; Risser, J. C. ; and Ferguson, A. B.: Scoliosis Treated by the Fusion 
Operation. An End-Result Studj"- of Three Hundred and Sixty Cases. J. Bone and 
Joint Surg., XIII, 91, Jan. 1931. 

Risser, J. C., and Ferguson, A. B. : Scoliosis: Its Prognosis. J. Bone and Joint Surg., 
XVIII, 667, July 1936. 


the journal of bone and joint SUROER-i 





392 


P. D. WILSON 



THE JOURNAL OF BONE AND 


JOINT surgery 


Fig. 6 — Case 6. 



SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


395 


thesia. Through a lateral incision over the left trochanter, a Smith-Pctersen nail was 
inserted under roentgenographic guidance. A small incision was made over the right 
trochanter, and the nail on this side was removed. Full mobility of both hips was per- 
mitted immediatelj". The patient was discharged one week after operation, walking on 
crutches, and full weight-bearing was not allowed until the end of four months. 

TtTien last examined on December 31, 1937 (in the illustration the roentgenogram is 
shown reversed), she had full use of the legs and there was no complaint. The leg length 
was equal, and there was free and painless motion in both hips. The measurements were 
as follows : 


Left Right 

Length 31 inches 31 indies 

Abduction 30 degrees 30 degrees 

Adduction 20 degrees 20 degrees 

External rotation 50 degrees 50 degrees 

Internal rotation 10 degrees 30 degrees 

Flexion 115 degrees 117 degrees 

Extension Normal Normal 


Case 5 (H23-600). D. F., male, aged sixteen, was admitted on August 26, 1930. 
He gave a historj' of pain in the right hip of intermittent character for a period of two or 
three j’ears, but continuous during the previous few months. There was no history of 
iniur 3 ^ Physical examination showed an obese boy walking with a definite right-sided 
limp. There was one-half an inch of shortening of the right lower extremity. Tlie rigid, 
hip was held in slight fixed external rotation, and there was slight limitation of abduction. 
The other motions were free. The roentgenographic examination revealed a slipped 
femoral epiphysis with moderate coxa-vara deformitj’. 

An operation was performed on August 28, 193C, and a Smith-Peter.'-cn nail was 
inserted by the Wescott method. After two weeks of liospitalization, the patient was 
discharged walking on erutches. Full activities were resumed at tlic end of four montlis. 
The nail was removed on May 14, 1937, approximately nine months after insertion. 

When last e.xamined on December 22, 1937, sixteen months after nailing, the patient 
stated that he had participated actively in sports and was entirely well. There was no 
limp. The leg length was equal, and there was no significant limitation of motion. The 
roentgenogram showed union of the capital epiplu'sis and satisfactory po'.;ition. The 
measurements were as follows: 


i.ength 

Circumference of thighs 

.Abduction 

External rotation 

Internal rotation 

Flexion 

Extension 


Left 

34 inches 
2331 inches 
50 degrees 
45 degrees 
10 degrees 
135 degrees 
Normal 


Right 

34 inchc.s 
23 inches 

35 degrees 
55 degrees 

5 degrees 
134 degrees 
Normal 


Cask 6 (H24— 1401. H. P., male, aged twelve years and seven months, w.is fjr-t 
seen on October 10, 1936, at which time he complame<l of jiain in the lateral :i-|K'ct of the 
left knee. Diter jiain developed in the region of the hip. Examination slioued one- 
fourth of an inch of shortening of the left leg. Then- was slight re-tnetion of intem;il 
rotation and of flexion. Hy]>ere.\tension was increa^e<i. Iloentgenogniplin- examination 
showed early slipping of the left fcmor.il epiphysis. 

The patient was admitted to the hospital on NovemiKT 16. lO.'Pi, and nailing throngh 
a later.il incision under roenlgenogr.iiiliic contnd was jicrformeil on November IS. lo3i’i. 
He Was ])crmitte<l iqi a few days later and was flischargeil on .lamniry ‘J, Iti.'iT. waiting 
with a niised shoe on the right and cnilclass. rail weight-lK-anng was is rinilted a! the 
end of two and onis-lialf month', .and the patient quickly n-i-ovcrod norm d funet’ori. Ho 
Was readmitted one year later and the nail wa- rcmoviai. 


Vol. \x xo ; Afiul. l'.e,s 



394 


P. ». WILSON 





SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


397 


When last examined on Dceember 22, 1937, thirteen months after tlie first, operat ion, 
he presented no complaints. There was a normal raiiRe of motion of the affected hiii, 
and the lower extremities were of equal length. The roentgenogram showed fusion of t he 
capital epiphysis. Comparative measurements of the hips were, as follow.s; 


Lffl Right 

Length 3 I?.| inches 3-1 'I ( inches 

Abduction 30 degrees -13 degrees 

Adduction Normal Noi-inal 

External rotation -15 degrees -15 degrees 

Internal rotation 20 degrees 30 degrees 

Flexion 120 degrees 125 degrees 


Case 7 (H24-151). J. B., male, aged fourteen years and six months, was first 
examined in the Clinic on November 9, 1930. He gave a history of pain in the left hip of 
five weeks’ duration, which had begun with a sudden click while walking. Examination 
showed a slender boy with a left-sided limp. Restriction and guarding of all movements 
of the left hip were noted. The log length was equal. Roentgenographic examination 
showed widening of the epiphyseal line of the left hip witli evidence of begiiming slii)]ung. 
The patient was admitted to the hospital immediately, and an oiierat ion was ])erfoi-med 
on November 13, 1936. A Smith-Petersen nail was introduced under rocntgenogra]ihic 
guidance by the usual technique without any effort at reposition of the head. A one-incli 
lift was placed on the right shoe. The patient was permitted to walk with crutclics and 
was discharged on December 10, 1936. He was allowed to walk normally at the end of 
two months. He was readmitted to the ho.spital thirteen months after operation, at 
which time there was fusion of the capital epiphysis, and the nail was removed. 

Examination on December 7, 1937, showed normal function and no comidaini . The 
leg length was equal. The comparative measurements of length and hip motion were 
ns follows: 


Left Right 

Length 34 ' 4 inches 3-1 ! 4 inches 

Abduction 42 degrees 13 degrees 

External rotation 45 degrees 50 degrees 

Internal rotation 30 degrees 35 degrees 

Flexion 125 degrees 120 degrees 

Extension Normal Normal 


Case S (1126-116). R. F., female, aged twelve years and eight months, was first 
seen in May 1937 because of intermittent pain in the left hij), which had begun one year 
previously following a fall. E.xamination .showed a large overweight girl who walked 
with a slight limp on the left. The length of the lower extremities was equal. Slight 
restriction of abduction of the left hip and slight fixed external rotation were pre.'-ent. 
The roentgenograms .showed slight downward and backward displacement of the left 
upper femoral epiphysis and irregularity along the epiphy.seal cartilage. 

The ])ationt was admitted to the hospital on ,Iune 7, 1937, and an operation was per- 
formed on .Tune 9. Under gcncinl anaesthesia and without any attenqit at reposition of 
the head, a lateral incision was made over the greater trochanter and a Snnth-Pelersen 
nail was inserted under roentgenographic guidance. Following ojiei-ation, the patient 
was kept in bed for four weeks with light extension on the leg, and was then allowed up 
with a raised .sole and crutches. She was discharged on .Inly 17, 1937. I'ull weight-bear- 
ing was permitted at the end of two months. 

When last examined on December 22, 1937, she pre.-ented no complaints and walkisl 
very well. There was one-half an inch of sbortennig of the left leg n ith slight limitation 
of internal rotation. The roentgenogram shoneil ginxl position and the epiphy.sis fu-ed. 
Comparative measureinent.s were as follows: 


voi. x.x. ■> Artiii. ions 



396 


P. D. WILSON 



Fig. 9 — Case 9. 





SLIPPING OF THE UPPER FEMORAL EPIPHYSIS 


399 


Digby, K. H. : The Measurement of Diaphysial Growth in Proximal and Distal Direc- 
tions. J. Anat. and Plu'sioh, L, 187, 1916. 

Ferguson, A. B., and Howorth, M. B.: Slipping of the Upper Femoral Epiphysis. A 
Study of Seventy Cases. J. Am. Med. Assn., XCVII, 1867, 1931. 

Gray', Henry': Anatomy of the Human Body. Ed. 20. Philadelphia, Lea & Febiger, 
1918. 

Jahss, S. a. : Displacement of the Upper Epiphysis of the Femur (Adolescent Coxa Vara) 
Treated by Closed Reduction. J. Bone and Joint Surg., XIII, 856, Oct. 1931. 

Milch, Henry': Epiphysiolysis or Epiphyseal Coxa Anteverta. J. Bone and Joint 
Surg., XIX, 97, Jan. 1937. 

PiERSOL, G. A.: Human Anatomy. Ed. 4. Philadelphia, J. B. Lippincott Co., 1913. 

Waldenstrom, Henning: On Necrosis of the Joint Cartilage by Epiphyseol 3 'sis Capitis 
Femoris. Acta Chir. Scandinavica, LXVII, 936, 1931. 

Necrosis of the Femoral Epiphj’sis Owing to Insufficient 
Nutrition from the Ligamentum Teres. A Clinical Study Mainlj^ Based on Experi- 
ences of the Treatment of Epiphj'seolysis Capitis Femoris. Acta Chir. Scandinavica, 
LXXV, 185, 1934. 

Wardle, E. N. : Etiologj^ and Treatment of Slipped Epiphj'sis of the Head of the Femur. 
British J. Surg., XXI, 313, 1933-1934. 

Wescott, H. H. : a Method for the Internal Fixation of Transcervical Fractures of the 
Femur. J. Bone and Joint Surg., XVI, 372, Apr. 1934. 

Wilson, P. D.: Conclusions Regarding Treatment of Slipping of Upper Femoral 
Epiphysis. Surg. Clin. North America, XVI, 733, 1936. 


'■OL. XX. XO. 2. ARRII. 



398 


P. D. WILSON 


Left Right 

Length 30 inches 30)4 inches 

Abduction 35 degrees 38 degrees 

External rotation 50 degrees 50 degrees 

Internal rotation 10 degrees 20 degrees 

Flexion 140 degrees 150 degrees 


Case 9 (H20-882). C. S., male, aged fifteen years and six months, was admitted 
to the hospital on September 9, 1937, with a histoiy of intermittent but progressive stiff- 
ness and pain in the right hip of one year’s duration. There was no definite relation to 
trauma. Examination showed an obese boy, of the hypopituitary ti’^pe, with slight 
bilateral knock-knee and a marked left-sided limp. The motions of the left hip were 
limited in abduction, adduction, and internal rotation. External rotation was normal, 
and hypej-extension was increased. The roentgenogi’aphic examination at this time 
showed I’arefaction in the line of the epiphj'seal cartilage and slight downward and 
backward displacement of the femoral head. 

An operation v'as perfoi-med on September 17, 1937, and a Smith-Petersen nail was 
inserted bi' the usual technique without any attempt to replace the head. The patient 
was discharged two weeks later on crutches, and weight-bearing was prohibited for three 
months. 

When last examined on December 28, 1937, thr ee and one-half months after nailing, 
the hip was painless, and thei-e was scai-celi' ani”^ limp. The I'ight extremity showed 
shortening of one-fourth of an inch, and there was scarcely an}"^ appreciable limitation of 
motion. The roentgenographic examination showed the nail still in place and the 
epiphysis in good position and beginning to fuse. Comparative measurements were as 
follows : 


Left Right 

Length 351^ inches 35 inches 

Abduction 30 degrees 35 degrees 

Adduction 15 degrees 15 degrees 

External rotation 45 degrees 40 degrees 

Internal rotation 0 degi-ees 5 degrees 

Flexion 120 degrees 125 degrees 


SUMMARY 

The diagnosis of slipping of the upper femoral epiphysis at an early 
stage, when the displacement is still minimal and not sufficient to cause 
any permanent functional impairment, permits an entirely different type 
of treatment from that which is necessary when serious deformity is 
present. Since early diagnosis depends chiefly upon the general prac- 
titioner, there is need of better instruction in the pathological and clini- 
cal appearances of this disease. 

For epiphyseal slipping with minimal displacement the author ad- 
vocates the insertion of a Smith-Petersen flanged nail under rocntgono- 
graphic control, without arthrotomy of the hip. The advantages of tins 
method are security and fixation, hastening of epiphyseal fusion, freedom 
from immobilization, and simplicity of after-care. This operation has been 
performed in nine ca-scs with e.xcellent results in all. Significant shorten- 
ing of the extremit3'' did not occur. 


references 


Bazix: Peiromil communication. , • i 

CoH.v, Isidore: Normal Bone.^ and .loints. New York, Paul B. llocher, Inc 

THE JOUR.VAI. OI 


192-1. 


r no.vi; an'o joi.vt scroeri 



TUBERCULOUS OSTEITIS OF THE ISCHIUM 

BY RAGNAR MAGNUSSON, M.D., BORAS, SWEDEN 
From Apdviken Const Sanatorium* Varbcrg, Sweden 

As tuberculous osteitis of the ischium seems to be little known, and 
as only occasional cases have as yet been published, the author feels justi- 
fied in giving a short account of the eight cases which were treated at 
Apelviken Coast Sanatorium from 1928 to 1936; these constituted 0.2 
per cent, of the cases of bone tuberculosis treated during this period. 
At the same time, five other cases of osteitis of the ischium, of uncertain 
etiology, were treated. Three of these are probably to be denoted as 
cases of clear septic osteitis, while the origin of the other two cases is un- 
certain. Only a short account of these will be given in connection with 
the differential diagnosis. 

Of the patients suffering from tuberculous osteitis of the ischium six 
were male and two were female. In five cases the left ischium was the 
seat of the tuberculous infection; in three cases the site was the right 
ischium. 

The course of tuberculous osteitis of the ischium is insidious and pro- 
tracted. In the cases upon which this report is based it made its first 
appearance as slight pain of the sciatica type. In one case (Case 5) the 
pain started after trauma, and in one case (Case 3) the symptoms set in 
after childbirth. (As a matter of fact, it has often been observed that a 
previously latent bone tuberculosis flares up in close connection with 
childbirth.) During the course of the disease also, the pain, which in most 
of the cases lasted for a year or more, was of a very mild type, so that 
the patient was able to go about his work as usual. Later on, however, 
localized 'pain over the tuber ischii was present; this was especially pro- 
nounced when the patient was seated. However, in most cases the pain 
did not cause much discomfort. 

Gradually, abscesses or fistulae appeared in the gluteal region, and not 
until then did the patient seek medical aid. In one or two rare cases these 
subjective symptoms occurred periodically, with shorter or longer inter- 
vals without symptoms. In one case (Case 2) a fistula appeared in the 
gluteal region coincident with the setting in of the pain. In nearly all 
cases the clinical examination showed tenderness to palpation over the 
tuber ischii, which could also be felt to be raised and thickened. 

In two cases (Cases 3 and 5) the patient also had subjective symp- 
toms from the hip joint of the same side as the affected ischium. These 
symptoms consisted of a sensation of stiffness in the hip joint, at times 
associated with pain, radiating from the hip joint down along the leg. 
In addition, it was possible at the clinical examination to establish a 

* Chief of Surgerj': Robert Hanson, M.D. 


VOL. XX. NO. 1, JANUARY 103S 


23 



LATERAL INTRODUCTION OF THE SCREW-BOLT IN 
INTRACAPSULAR FRACTURE OF THE HIP * 

BY MYRON O. HENRY, M.D., MINNEAPOLIS, MINNESOTA 

In 1932, the author devised a rustless-steel screw-bolt for fixing the 
head onto the shaft in true intracapsular fracture of the hip, a principle 
of treatment previously shown to be sound in animal experimentation b 
The original method ^ afforded excellent visualization of the fracture, 
permitted removal of interposed soft tissues, and enabled accurate intro- 
duction of the screw-bolt. Although close coaptation of the fragments 
was secured, the method required a major surgical operation which could 
be conscientiously advised in only a few selected cases. While internal 
fixation under direct exposure has many enthusiastic supporters, there 
has been a continuous search for a satisfactory means of introducing 
reliable fixation by a less extensive lateral surgical exposure. The sound 
mechanics of the screw-bolt principle for internal fixation of fractures of 



Fig. 1 


Special instruments for lateral screw-bolting; (a) 
tractor; (c) steel rule; (d) Kirschner wires, of equa graduated 

Watson Jones pin; (/) hollow reamer; (g) improved scrcu-bolt and socket 

wrench; (/i) screw driver. 

* Presented before the British Columbia Medical Society, Vancouver, British 
Columbia, September 14, 1937. 


400 


the: jour-vai. of bon'e a.vd joi.vt .sunoF.R'i 




402 


M. O. HENRY 



Fig. 3-A Fig. 3-B 

Fresh intracapsular fracture reduced KirscJmer ivire in situ. 

in traction. 


the hip has appealed to others, and the author has developed a simple 
method of accurately introducing his rustless-steel screw-bolt through a 
small lateral incision. Only a few special instruments (Fig. 1) are re- 
quired. If properly introduced, the screw-bolt does not tend to wander 
or to slip out, and bony union has been secured with it in spite of partial 
absorption of the neck. The improved method of lateral introduction 
is as follows: 

The sound hip is x-rayed Avith a graduated marker (Fig. 2-A) and 
taped to the skin alongside the trochanter, as advocated by Schanz of 
Dresden. On such a roentgenogram of the sound hip, the angle of the 
femoral neck is measured precisely with a protractor. The exact length 
of the neck shadow, from the optimum point on the trochanteric side to 
the point of desired penetration into the head, is measured on the film 
with a steel rule. The exact length of screAA^-bolt penetration can then 
be computed * as the real length of the Schanz marker is knoAAui. 

The fractured hip (Fig. 2-B) is reduced under general or local anaes- 
thesia by the Leadbetter manipulation, and both extremities are put up 
in traction on the fracture table in moderate abduction (Fig. 3-A). Next 
a six-inch incision is made distal to the trochanter, and the upper femoral 
shaft is exposed subperiosteally. Two heavy Kirschner Avires of exactly 
the same length are needed. One AAure is introduced carefully Avith the 
hand drill at the angle set on the protractor as previously determined from 
the roentgenogram of the sound side. The exact amount of penetration 
is measured from time to time during insertion by removing the drill, 

* Formula: Shadow of marker (measured on film) is to actual length of marker 
(known in inches) as shadow of neck (measured on film) is to real length of neck IT). 
The desired penetration is usually three and one-half to four inches. 

THE JOtinX.^L OF nO.N'E A.VD JOI.N'T .SURGI.nA 




INTRACAPSULAR FRACTURE OF THE HIP 


403 



Fig. 4-A 


Hollow reamer following wire (Watson 
Jones guide pin not used in this case — 
note slipping of head). 



Fig. 4-B 


Accessor}' pin to prevent rotation of 
head. Serew-bolt in place. 


placing the second wire against the bony 
cortex along.side the first, and measuring 
the projecting remainder of the second 
wire over the inserted wire. By proceed- 
ing in this way there is no risk of pene- 
trating the joint or the pelvis, and the 
guide wire can be introduced the exact 
predetermined distance (Fig. 3-B). An- 
teroposterior and lateral roentgenograms 
are made to verify the position of this 
guide wire; if it has not been precisely 
placed, the wire is withdrawn and intro- 
duced again, and the position verified 
with x-rays. A Moore pin or an en- 
graved, graduated Watson Jones pin is 
inserted with a hand chuck along.side the 
guide wire, so as to engage the head and 
prevent rotation or displacement of the 
head temporarily (Figs. 4-A and 4-B). 

A graduated, hollow hand reamer, which 
follows the guide wire, but does not cut it, is used to bore a channel 
from the trochanteric side, so as to just enter the head. This is usually 
a distance three-quarters of an inch less than the penetration of the wire, 
and one must not cut too deeply into the head for fear of jeopardizing the 
firm bite of the whole screw tiji in the bone of the head. The reamer and 
Kirschner-wire guide arc withdrawn, and the rustle.«.^-.steel screw-bolt is 
screwed into the unreamed head with a screw driver. The Wat.son Jones 
guide pin prevents rotation or displacement of tlie head during (his 

voi,. XX. xo. i .Aran. 



Fig. 5 

End result. Screw-bolt and pin 
withdrawn. 



404 


M. O. HBNKY 


manoeuver. The femoral head is then drawn tightly back onto the neck 
by tightening the machine-screw nut against a curved washer on the 
trochanteric end of the bolt. If the socket Avrench is used, one must be 
careful not to strip the threads. Check-up roentgenograms are again 
made in two planes before the Watson Jones pin is withdraAvn and the 
wound is closed. 

No external fixation is necessary, and early motion of the extremity 
is encouraged to improAm the local circulation. The protruding end of the 
bolt under the skin keeps the patient from lying on the affected hip dur- 
ing the healing period. Weight-bearing is lAot permitted for six months, 
or until roentgenograms reAmal good bony union (Fig. 5). 

After a thorough trial of Aveight-bearing, the entire screAA^-bolt and 
AAmsher can be remoAmd, if desired, through a small lateral incision under 
novocain; the screAA’^-bolt is simply unscreAved with a screw driAmr. 

REFERENCES 

1. Henra", M. 0. : Proximal Osteosj^nthesis in Intracapsular Fracture of the Hip. 
An Experimental StudJ^ J. Bone and Joint Surg., XIII, 530, July 1931. 

2. Henry, M. 0. : Intracapsular Fractures of the Hip. A New Device for Lateral 
Osteosynthesis. J. Bone and Joint Surg., XVI, 168, Jan. 1934. 


THE JOURNAL OF BONE AND JOINT .SURGERY 



CORRECTION OF SCOLIOSIS BY A DISTRACTOR APPARATUS 


BY JOHN DONALDSON, M.D., ELIZABETHTOWN, PENNSYLVANIA, AND 
O. ANDERSON ENGH, M.D., WASHINGTON, D. C. 

From ihe State Hospital for Crippled Children, Elizabethtown, Pennsylvania 

The principle of distraction for the correction of scoliosis is not new. 
The most commonly used method is that with the turnbuckle apparatus. 
We wish to present our method and to show some of the results. Although 
it has been tried in only six cases, it has produced a fair correction in each. 

Three of the cases were due to infantile paralysis; one was caused by 
a pyogenic hip; and the remaining two were of unexplained etiology. 
The six patients ranged from thirteen to seventeen years of age. Three 
were boys and three were girls. Other forms of treatment had been tried 
previously without much success. Rotation of vertebrae was observed 
in the roentgenograms of five of the patients, who also had an accom- 
panying kyphosis. 

Our method is to apply a snug, well-molded body cast, with the pa- 
tient lying on a Hawley table. We use an adjustable stand beneath the 
prominence, so as to obtain slight hyperextension. No felt is used and 
only a small amount of sheet wadding is applied over the bony promi- 
nences. Assistants maintain slight traction to the head and legs during 
the application of the plaster. It is important that the bandages are 
rubbed well, so as to produce a hard, light cast. It should extend high 
on the chest and low over the pelvis. The distractors are added to each 
side by simply wrapping a few rolls of plaster around them. 

The threaded-tube type of distractor (Fig. 1) vhich we devised is 




Fig. I 

Tlirc.idwi-tiibe tj'pe of distractor. 


VOL. XX. xo. 2. Aruii. loss 


•tO.i 



Fig. 2-A Fig. 2-B Fig. 2-C 


CO ^ 

O c 

rH 0 

S (fi 
«!> 

VI o 

0 2 S 

^ ^ 

)-5 0 ) 

•'0 4 ^ 

oHo 


t3 

d S rf 

O h 

s.s-S 

.5<s1 

ID -s o 


)INT .SURGKK 


lower than in Fig. 2-A. 








THE JOURNAL OF BONE AND 


JOINT SURGERV 



CORRECTION OF SCOLIOSIS BY A DISTRACTOR APPARATUS 


409 


superior to loose turn- 
buckles or the exposed- 
thread tyiie, which we 
formerly used. They 
can be entirely incor- 
porated in the plaster, 
making application 
easy; they are com- 
fortable; and the5’^ are 
not Ausible under cloth- 
ing. Four days are 
required for dr5ung. 
Then the cast is split 
horizontallj'^ (opposite 
the apex of the curva- 
ture if possible), pro- 
ducing lower and 
upper portions. Dis- 
traction must be slow 
and gradual. A quar- 
ter of a turn daily is 
sufficient. If the pa- 
tient complains of 
“burning”, it is best 
to postpone the dis- 
traction for a few 
days. In one of our 
cases, in which dis- 
traction was rapid, 
a pressure sore developed. 



Fig. 4-C 

Case 3. W. E., December 6, 1937. Final roentgeno- 
gram showing tibial graft. Patient 

supine. There has been an increase 
in height of eight inches. 


Usually a few days are re- 
quired before the ascending portion of the cast grasps 
the upper thorax and the descending portion grasps 
the pelvis. The circumference of the upper thorax 
and of the pelvis is greater than of the intervening 
region, causing the spine to be stretched between them. 
Each distractor is turned an equal distance. Ivo 
attempt is made to increase the correction on one side. 

After satisfactory correction has been obtained, a 
brace may be applied. Sometimes the spread is main- 
tained bj"- wooden wedges and a fusion operation is per- 
formed through a window in the back of the cast. In 
Case 1 , we applied three distractor casts, decreasing 
the curvature each time. However, each case is an 
individual problem and it is beyond the scope of this 
paper to discuss the jirocedure, once satisfactory cor- 
rection has been obtained. 



Fig. -l-D 

C.a?e 3. \V. 
in witii 

tractors. 


E., 

dis- 


VOL. XX. XO. 2, APIIIL IMS 




410 


J. DONALDSON AND O. A. ENGH 


The patient in Case 1, whose condition was due to destructive hip- 
joint disease, was made ten inches taller by the apparatus. She was in 
the hospital for over a year. During this time she also had several opera- 
tions on the involved leg. This permitted us to proceed gradually. The 
patients in Cases 2 and 3, in whom the scoliosis was the result of infantile 
paralysis, were made three and one-half and five inches taller, respec- 
tively, after one month’s treatment. In Case 3 the patient was ambulant 
during treatment. The correction in these cases is easily recognized in the 
roentgenograms. The marked lowering of the pelvis and the decrease in 
angulation are well demonstrated. 

We do not believe that a distractor apparatus should be used in eA^ery 
case of scoliosis. The principle of correction must be borne in mind. 
Although Ave obtained good results in all our cases, Ave Avere careful to 
choose the types of patients suited for this procedure. It should not be 
attempted on an obese indiAudual or on one AAuth poor chest development. 
It is a good plan to measure the abdomen and upper chest and if the latter 
is not a feAV inches greater the procedure should not be attempted. 

We have not found it necessary to incorporate the chin and pelvis in 
the cast as is done by Moore. In all our cases, simple body casts Avere 
sufficient. We do not keep all our patients in bed. The fact that in Case 
3 an increase in height of fiA'^e inches Avas obtained after one month of 
treatment has encouraged us to try this method in the future AAdienever 
feasible. We belleA'^e in some instances that it is a good plan to combine 
or to alternate simple distraction Avith the methods of Hibbs, Risser, and 
Ferguson, Galeazzi, and others. 

REFERENCES 

Galeazzi, Riccardo: The Treatment of Scoliosis. J. Bone and Joint Surg., XI, SI, 
Jan. 1929. 

Hibbs, R. A.; Risser, J. C.; and Ferguson, A. B.: Scoliosis Treated by the Fusion 
Operation. An End-Result Stud}" of Three Hundred and Sixty Cases. J. Bone and 
Joint Surg., XIII, 91, Jan. 1931. 

Moore, J. R.: Personal communication. 


THE JOURNAL OF BONE AND JOINT .‘lOnOER 



TREATMENT OF LOCALIZED FIBROCYSTIC CAVITIES IN 
BONE BY CURETTAGE AND PACKING WITH BONE CHIPS * 

BY WALKER E. SWIFT, M.D., AXD HALFORD HALLOCK, M.D., F.A.C.S., 

XEW YORK, X. Y. 

From the New York Orthopaedic Dispensary and Hospital 

One of the interesting moments in an orthopaedic surgeon’s practice 
occurs when he examines the roentgenogram of a patient and sees a cavity 
in the shaft or near the end of one of the bones. Of the lesions which can 
cause such a cavity, those under discussion in this paper comprise a group 
which are relatively benign, and yet, if left to their own devices, show a 
tendency to progressive expansion and absorption of the bone with the 
production of pain, deformity, and disability. According to present-day 
pathological conceptions, they seem to belong to the same family which 
may be called by the surname of localized fibrocystic disease of bone, and 
they seem to exhibit many similarities of clinical appearance and behavior. 
On the other hand, they do show marked differences of the actual local 
pathology, on the basis of which they have been divided into the following 
three groups for purposes of this study: (1) lesions which are found to be 
cavities in the shaft of the bone, filled with fluid and surrounded by a 
limiting fibrous membrane, called bone cysts; (2) lesions which are cavities 
in the shaft of the bone, filled with firm, cellular, fibrous tissue, described 
as osteitis fibrosa cystica; and (3) lesions which are cavities at the epiph- 
ysis, filled with soft, vascular tissue of characteristic microscopic ajv 
pearance, diagnosed as giant-cell tumors. 

As this paper is concerned with treatment, we shall pass over the 
interesting questions which arise in a discussion of the etiology and nature 
of these lesions, and confine ourselves to the way in which they have been 
treated at the New York Orthopaedic Dispensary and Hospital, and with 
what results. 

The problem of treatment is twofold: how to stop the activity of the 
disease, for we know it maj'^ progress if left alone; and how to set the stage 
so that orderly repair processes maj’' restore the bone to a healthy state. 
Although some men have handled this problem bj*^ the use of roentgeno- 
therapy and others by surgical curettage and cauterization, reporting 
more or less satisfactory results, the surgeons at the New York Ortho- 
paedic Hospital have dealt with it surgically liy curettage of the cavity, 
followed by packing it with bone chips without cauterization. The ad- 
vantages of this approach arc several. In the first place, a more exact 
diagnosis is possible if the lesion is actually seen and tissue from it is stud- 
ied microscopically. Second, if the diseased tissue is removed a-; com- 

* Read at the Annual Meeting of the .American .Aca<iemy of Orlliopaodic .''urpeons, 
Ix)s .Anpeles, California, .lanuary 20, 1 038. 

voi., XX. N-o. e. . 


.\rnii. 


•ill 



24 


RAGNAR MAGNUSSON 



Fig. 1-A 
Case 1 


restriction of abduction and adduction and 
of the rotatory movements in one of the cases 
(Case 7). These symptoms from the hip joint, 
however, disappeared during the patient’s stay 
at the hospital, and on discharge from the hos- 
pital it Avas not possible in a single case to es- 
tablish any symptoms of an affection of the hip 
joint. The roentgenograms of these three cases 
in Avhich there Avere symptoms from the hip 
joint show that the destruction Avithin the 
Fig. 1-B ischium reached the acetabulum. (See Figures 

Case 1 3-A, 3-B, 4-A, 4-B, 5-A, 5-B, and 8.) The read- 

iest explanation of the occurrence of symptoms 
from the hip joint in these cases is, AAothout doubt, that they are due to an 
irritation from the juxta-articular focus. All three of these patients AA'ere 
operated on. At operation, in Case 3, the destruction of the superior 
ramus AA’as found to haA^e reached the loAver edge of the acetabulum. In 

THE JOURNAL OF BONE AND JOINT SURGERA' 





LOCALIZED FIBROCYSTIC CAVITIES IN BONE 


413 



Fig. 2-A Fig. 2-B Fig. 2-C Fig. 2-D 

Bone C 3 ’st filled irith fluid in the upper end of the humerus of a female, eight 
jvars old. There were no symptoms until a fracture through tlie lesion occurred. 
The fracture united, but the lesion progressed. 

Fig. 2-A : Cavity in humerus before curettage and packing with chips. 

Fig. 2-B: Five months after operation. The lesion was thought to be healing, but 
at the end of sixteen months a recurrence was noted. 

Fig. 2-C: Three years after operation. The lesion had become larger and at op- 
eration it was found to be filled with fluid. The cavity was curetted and packed with 
chips. 

Fig. 2-D: Two years after the second operation. Lesion healed. 

definite stimulus to the osteogenic-repair process and that their presence 
materially hastens the healing of the cavity. 



Fig. 3-A Fig. 3-B Fig. 3-C 

Osteitis fibrosa in the shaft of the femur of a female, eiglitcen years old. The 
symptoms were of seven years’ duration. There had been a steady incre.ase in the 
size of the lesion in spite of three courses of roentgenotherapy. 

Fig. 3-A: C.avity in femur before curettage and packing with chips. 

Fig. 3-B: Five months after operation. 

Fig. 3-C: Eight years after operation. I.^sion iiealed. 


VOL. XX, XO. 2. AVUIL 103S 



412 


W. E. SWIFT AND H. HALLOCK 



Fig. 1-A Fig. 1-B Fig. 1-C 

Bone cyst filled with fluid in the lower end of the femur of a male, three years old. 

There were no symptoms. Swelling of the knee was noted b 3 '^ the child’s mother. 

Fig. 1-A: Cavity before curettage and packing with bone chips. 

Fig. 1-B : Two months after operation. 

Fig. 1-C: Two and one-half j'ears after operation. Lesion healed. 

pletely as possible, it would seem that the processes of repair ivould have 
the best environment in which to function. Third, if the cavity is filled 
with small bone chips, a framework for the new, vascular, fibroblastic 
repair tissue is provided, as well as a concentrated source of calcium and 
phosphorus salts which will be available at the place where they are needed 
as soon as local conditions are right for the formation of new bone. 

Our conception of the process of repair that occurs in a cavity which 
has been filled with bone chips may be stated briefly. Blood or serum 
fills the spaces around the individual chips. As clotting takes place, the 
fibrin network binds the bone chips together, and the whole area then be- 
comes infiltrated by a rapidly growing, vascular, fibroblastic tissue. The 
bone chips themselves quickly lose their individual cells and, if examined 
under the microscope after a few days, will appear like dead bone. How- 
ever, in spite of this, and as early as the second week, a layer of new bone 
is formed around and intimately adherent to the outer suiface of eac i 
chip, while trabeculae of new bone appear in the narrow spaces between 
the chips. These trabeculae ivill join the new bone formed around tlie 
chips, so that a network of trabeculated bone is developed with the ap- 
parently dead chips as integral parts. The old cliips may remain and be 
recognizable for a long time, but they do not seem to act as irritating 
foreign bodies or sequestra, nor do they appear to encourage the deve op- 
ment of giant colls around their margins. Eventually they lose tncir 
identitv through some process of resorption as the structuie o t ic ion 
approaches nearer to a healthy state. It is felt that the bone c ups ac 

Tin: jounsAL of hose an'd joint sunGi.ni 



LOCALIZED FIBROCYSTIC CAVITIES IN BONE 


415 


Osteitis Fibrosa 

There were fifteen patients in this group, — eleven females and four 
males of an average age of twelve years. The femur was involved six 
times, the tibia and the humerus each three times, and a metatarsal bone, 
a fibula, and a finger phalanx each once. These fifteen patients required 
twenty-three operations, as six of them had lesions which recurred after the 
first operation. One of these lesions, in a tibia, showed great persistence, as 
it returned three times in the original location and once higher up, so that 
this individual required five operations before a cure was effected. An- 
other patient had a lesion which recurred after a second operation. One 
patient had a large cavity in the trochanter and neck of the femur, which 
had been treated without effect by roentgenotherapy for one and one-half 
years. This patient was operated upon and seemed to be doing well for 
ten months, after which time the lesion recurred. This patient and the 
preceding one have been lost to the Follow-Up Clinic. Another patient 
has in the humerus a recurrent lesion of much smaller size than the original 
cavity, and during six years it has shown no tendency to increase, so that 
its character has probabl}'- been altered. A lesion in the upper end of the 
humerus recurred twice, but has been cured by the third operation. 
There was one recurrence in the phalanx of a finger, but the lesion has re- 
mained healed after the second curettage and packing with bone chips. 
The final results in this' group are shown in Table II. One patient, a 
child of seven, died of shock soon after the operation which was performed 
on a hot summer day. The lesion was a large one in the .shaft of the 



Fig. 4-A Fig. 4-B Fig 4-C 

pstcitis fibrosa in the upper part of the shaft of tlie femur in a male, si.v years old. 
Pain and a limp had been present for two months. 

Fig. 4-A : C.avity in the shaft of the femur before curettage and packing with chips. 
Fig. 4-B; One month after operation. 

Fig. 4-C: Seven years after operation. Lesion healed. 


VOI.. XX. XO. 2. .VPIllI. IMS 



414 


W. E. SWIFT AND H. HALLOCK 


TABLE I 

Analysis and Results op Six Cases of Bone Cysts 


Number of patients 

Average age of patients 

Number of recurrent lesions 

Number of operations for recurrence:. . . 

Curettage and bone chips 2 

Average time when recurrence was noted 
Average follow-up period 


6 

9 years 

2 (33 per cent.) 

2 (2 patients) 

15 months 

3 years 


Number of lesions healed 6 (100 per cent.) 

Number of lesions not healed 0 

Number of deaths 0 


That this type of repair is a complicated one, involving many chem- 
ical and pathological factors which are not understood, goes without say- 
ing, and, therefore, it is to be expected that some lesions may not follow 
the rule. There are recurrences after curettage and packing with bone 
chips, and here again it is hard to understand or to explain the factors in- 
volved. It is interesting that the actual pathology found in a recurrent 
lesion is usually similar to that which was seen in the original cavity, 
that is, the contents will be made up of either fluid, or fibrous tissue, or 
giant-cell tumor. It is also interesting that recurrent lesions treated by 
curettage and packing with bone chips will usually heal satisfactorily, al- 
though several operations may be necessary. 

The surgeons at the New York Orthopaedic Hospital began in 1922 
to treat fibrocystic cavities in bones by thorough curettage and packing 
with small bone chips usually obtained from the shaft of the tibia. Be- 
tween 1922 and 1935, twenty-eight patients who presented such lesions 
were treated in the manner outlined and the cases were classified according 
to the three groups which have already been mentioned, bone cysts, 
osteitis fibrosa, and giant-cell tumors. 


Bone Cysis 

These were six in number and occurred in the youngest age group, t ic 
average age being nine jmars. Four were m male.s and two m fema es. 
The humerus was involved three times and the radius, femur, and n m a 
each once Four of the six lesions were recognized after a fractui e at t len 
site - one was discovered because of pain; and one was found incidental to 
an examination for a foot complaint. Eiglit operations were performed on 
these six patients, as Uvo lesions locun-ed, each recunent l«»" ; 

cyst filled with fluid and without any evidence of bone chips. - • 

in this gfonp are shown in Table I. Bach patient has been we h n I 
roentgenograpliic evidence of healthy bone repair, for at least one >e. 
after operation. The average follow-up period is three yeais. 

Tlir. JOURNAL OF RONE AND JOINT SUROLRl 



LOCALIZED FIBROCYSTIC CAVITIES IN BONE 


417 


TABLE II 

Analysis and Results of Fifteen Cases of Osteitis Fibhosa Cystica 


Number of patients 

Average age of patients 

Number of recurrent lesions 

Number of operations for recurrence; 

Curettage and bone chips S 

Number of recurrent lesions not operated upon 

Average time when recurrence was noted 

Average follow-up period 


15 

12 years 
6 (40 per cent.) 
S (4 patients) 

2 

12 months 
4 j-ears 


Number of lesions healed 11 (73 per cent.) 

Number of lesions not healed 3 (20 per cent.) 

Number of deaths (operative) 1(7 per cent.) 


tion of the radius. Before surgery was used, the patient had had a 
long course of roentgenotherapy, sufficient to cause considerable necrosis 
of the lesion but not to effect healing. In two cases, a leg was amputated. 
In one of these, the lesion was in the os calcis, and for ten months after the 
curettage the condition seemed to be healing. Then a recurrence was 
noticed and, in spite of treatment by roentgenotherapy over a period of 
five months, the lesion continued to increase in .size. A second curettage 
Avas adAused, but declined, and the patient continued AA-ith roentgeno- 
therapy until the skin broke doAAm. Four years later the leg Avas ampu- 
tated because of persisting .sinuses and continuance of the lesion. In the 
other case, the le.sion AA’as in the lower end of the tibia, and the leg was 
amputated one month after the original curettage because the le.sion AA'as 
suspected of being malignant. Table III shows the results in this group 
of giant-cell tumors and demonstrates that all the patients liaA^e remained 
Avell for an aA^erage folloAA'-up period of fiA’^e j^’ears. 

TABLE III 

Analysis .and Results of Seven Cases of Gi.ant-Cell Tu.mop. 


Number of patients 

Average age of patients 

Number of recurrent lesions 

Number of operations for recurrence: 

Curettage and bone chips 3(1 patient; 

Amputation 2 

Average time when recurrence was noted 

-Vverage follow-up period 


IS years 
3 (43 per cent.) 
5 


10 months 
5 year.s 


Number of lesions healed 5 (71 percent.) 

Number of lesions not healed (amputation) 2 (20 per cent.) 

Number of deaths 0 


A'ol. xn. no. e. 


APIIII. 1P.IS 



416 


W. E. SWIFT AND H. HALLOCK 


fernur and had been present for at least two years, during which time there 
had been two fractures through the area without any tendency for the 
disease to become arrested, although the fractures had united. Eleven of 
the patients are considered to be entirely healed after a follow-up period 
averaging four years, and three patients have recurrent lesions. 

Giani-Cell Tumors 

Seven patients were included in this 
group, with an average age at the time of op- 
eration of eighteen years. There were five 
females and two males. The lower end of the 
tibia was involved in two cases, and in the 
other five cases the lesions were located in the 
upper end of the femur, in the upper end of 
the humerus, in the os calcis, in the lower end 
of the ulna, and in the pedicle of the third 
lumbar vertebra. In all, twelve operations 
were performed on these seven patients. One 
patient with a lesion in the lower end of the 
ulna had four operations before a cure was ob- 
tained, because the lesion recurred twice in 
the same site and once in the adjacent por- 



Fig. £-A 



Fig. 5-B Fig. 5-C Fig. 5-D 

Giant-cell tumor in the lower end of the ulna of a female, forty-two j'cars old. 
There had been a steady increase in the size and sj’mptoms for four years in spite 
of treatment bj' roentgenotherapy. 

Fig. 5-A : Lesion at time of curettage and packing with bone chips. • • i 

Fig. 5-B: One year after operation. Recurrrat lesion in upper part of original 
cavity. A second operation, consisting of resection and a bone graft, was perfornic . 

Fig. 5-C: Two j'ears after second operation. Lesion in ulna healed. New area 
of giant-cell tumor in lower end of radius. This was curetted and packed mi 
bone chips. Recurrence after one year. Lesion again curetted and packed. 

Fig. 5-D: One and one-half j'ears after fourth operation. Lesions in ulna a 
radius arc healed. 

THE JOUnXAL OF BONE .\ND JOIKT SUnGr.Kl 


SUBCUTANEOUS TENOTOMY OF THE ACHILLES TENDON 


BY JOHN T. HODGEN, M.D., AND CHARLES H. FRANTZ, M.D., 

GRAND RAPIDS, MICHIGAN 

From the Orthopaedic Division, Blodgett Memorial Hospital, Grand Rapids 

Tenotomy of the Achilles tendon is one of the simplest and most 
universal procedures in orthopaedic surgery. The surgeon, confronted 
with the problem of a short heel cord, usually chooses to obtain length by a 
plastic operation on the tendon or by a subcutaneous tenotomy. The 
decision depends largely upon the age of the patient, the etiology, and the 
degree of deformity. Lengthening of the tendon is not sufficient in itself 
in many instances and must be performed in conjunction with other 
operative procedures on the foot. The question of the relative value of 
the open plastic operation and the subcutaneous tenotomy arises. 

Both methods are universally described and accepted as good treat- 
ment. A number of authors make definite statements as to when and 
when not to employ subcutaneous tenotomy; others make no comment. 

Jones and Lovett warned against subcutaneous tenotomy in spastics 
and in cases of poliomyelitis. They stated definitely that they preferred 
the open plastic method. They did, however, utilize the subcutaneous 
section for the correction of club-foot in infants. 

Soutter stated that in large clinics, where thousands of tenotomies 
had been done, lack of union was almost never seen. He, nevertheless, 
seemed to favor zig-zag lengthening in preference to transverse section. 
These are opposing ideas. 

Whitman tells us that the open plastic operation is theoreticall}’- a 
safer procedure. He states, further, that subcutaneous tenotomy is 
preferable V'hen the tendon lengthening is an incident in the treatment of 
club-foot. These are also oppo.sing statements. 

Calot determines his method by the required amount of lengthening. 
For children, when the necessaiy correction docs not e.xceed one centi- 
meter, and for adults, when the correction does not e.vcced two and one- 
half centimeters, he uses the subcutaneous tenotomy. When the correc- 
tion required is greater than these figures, he recommend.s tlie open plastic 
method. 

Mercer utilizes the closed method for club-foot. He emplo3's both 
methods for .spastics. For the deformit3'^ following poIiom3'elitis, however, 
he emplo3\s only the open plastic metiiod. 

Moore described onl3’' the technique of subcutaneou.'; tenotom3' 
lengtlicning the heel cord in club-foot and in polionyelitis. 

Brockman emplo3^s onl3’- the .subcutaneous tenotom3' in club-foot. 

Galland, in 1924, discussed tlie poor results from subcutaneous sec- 
tion. He described a closed plastic lengthening which he much preferred 
to the .simple tenotony. 



418 


W. E. SWIFT AND H. HALLOCK 


TABLE IV 

SuMMAHY OF Twenty-Eight Cases of Fibrocystic Lesions 
Treated from 1922 to 1935 * 


Average 

Age of No. of Lesions Wliich Total No. 
Diagnosis Patients Patients Recurred of 

(Years) No. Per Cent. Operations 


Bone cyst 9 6 2 33.0 8 

Osteitis fibrosa 12 15 6 40.0 23 

Giant-cell tumor IS 7 3 43,0 12 

Total 28 11 39.0 43 


Results 

Diagnosis Lesion Healed Lesion Unhealed Amputation Death 

Cases Per Cent. Cases Per Cent. Cases Per Cent. Cases Per Cent. 

Bone cyst 6 100.0 0 0.0 0 0.0 0 0.0 

Osteitis fibrosa ... 11 73,0 3 20.0 0 0.0 1 7.0 

Giant-cell tumor. . 5 71,0 0 0.0 2 29.0 0 0.0 


Total 22 79,0 3 11.0 2 7.0 1 3.0 


* 28 patients had 43 operations; 1 patient died of shock; each of 2 patients had a leg 
amputated; 3 patients have unhealed lesions; 22 patients have healed lesions. 


SUMMARY 

The results obtained in the twenty-eight patients of the series are 
shown in Table IV and reveal several interesting comparisons between the 
three groups. These lesions have a marked tendency to recur locally, as 
demonstrated by a 39-per-cent, recurrence in this series. It is important 
to realize that the average time when the recurrences were noted was as 
late as one year, so that a long follow-up period is necessary. The local 
recurrences can be treated successfully in the same way as the original 
lesions, even though some cases may require several procedures before a 
cure is obtained. The three patients who still have unhealed lesions are 
all in the osteitis-fibrosa group, and two of them have been lost to the 
Follow-Up Clinic without having had the second operation which was 
advised. In the other case there is an unhealed area which has not in- 
creased at all over a period of six years. It is so small that further treat- 
ment has not been advised. 

Although 79 per cent, of the lesions have healed satisfactoril)’’, the 
variations in the percentage of success among the three groups must be 
noted. Because of the similarities which have been observed in the 
behavior of these lesions under treatment, it is believed that curettage and 
packing with bone chips is an effective method of dealing with them, anc 
that, as larger numbers are accumulated, the percentage result in eac 1 
group will tend to be more satisfactory. 

THE JOUR.VAL OF HONE A.VI3 JOI.N'T SUROI.R' 



TUBERCULOUS OSTEITIS OF THE ISCHIUM 


25 


Case 5 the focus 
reached to within 
three millimeters and 
in Case 7 to within 
scarcely one centi- 
meter of the articu- 
lar capsule. How- 
ever, similar juxta- 
articular foci both of 
a tuberculous and of 
an unspecific nature 
were present in two 
other cases (Cases 8 
and 13) udthout there 
having occurred any 
subjective or objec- 
tive symptoms from 
the hip joint, and at 
operation in each 
case it was possible 
to establish that the 
destruction had 
reached the acetabu- 
lum. On the other 
hand, pronounced 
symptoms from the hip joint, together 
with considerable restriction of mobil- 
ity, occurred in one case (Case 9) of 
certain septic origin, in which the 
changes were principally localized to 
the tuber ischii (Fig. 8). It is difficult 
to explain the occurrence of symptoms 
from the hip joint in some cases, while 
in others the patients remain free from 
symptoms under circumstances in other 
respects quite similar. Quite a number 
of reasons can be thought of as being of 
importance in this connection, such as 
the difference in virulence of the bacteria, less resistance to the infection 
in some patients than in others, etc. Odelberg, who described four cases 
of osteitis of the ischium of uncertain origin, stated that in one case the 
mobility of the hip joint on the affected side was restricted. In this case 
also the symptoms abated completely. It seems to be quite certain that 
those S3’mptoms from the hip joint which occur in osteitis of the ischium 
do not signifj^ the setting in of a fullj’’ developed coxitis. The information 
received from the patients goes to prove the same thing. 



Fig. 2-A 
Case 2 



Fig. 2-B 
Case 2 


VOL. XX. XO. 1. JAXUAHY 1038 



420 


J. T. HODGEN AND C. H. FRANTZ 



It would seem from these authors 
that plastic lengthening is the prefer- 
able method of procedure, but, despite 
the definite statements of some, the 
surgeon is left to make his own de- 
cision, largely from his own experi- 
ence. There is no doubt that in the 
rmst majority of subcutaneous tenot- 
omies performed on the heel cord firm 
union results. However, not infre- 
quently come to our attention patients 
whose functional results are not of the 
best. These unfortunate patients pre- 
sent an atrophied gastrocnemius, a 
threadlike heel cord, and a pes cavus. 
(See Figure 1.) 

The development of this deformity 
is fairly clear. Behind the external malleolus the peronei run posterior 
to the transverse axis both of the ankle and of the midtarsal joints. 
The}’’, therefore, act as flexors. The posterior tibial tendon runs in like 
manner behind the medial malleolus, and also acts as a flexor to the ankle 

and midtarsal joints. (See Figure 2.) 

Normally, these muscles act synchronously with the gastrocnemius, 
the soleus, and the plantaris. The Achilles tendon, partially or wholly 
ununited, either does not act in its normal capacity or fails to function. 
The body of the os calcis, then, is not acted upon directly in plantar 
flexion. In an attempt at plantar flexion, midtarsal flexion occurs fiist 
bj'’ the action of the jDeronei and tibialis posterior plus the long toe flexors 
(Fig. 2). When the forefoot is thus flexed, there follows slight excursion 
of the os calcis (Fig. 3). This action decreases the distance between the 

origin and insertion of the short toe flexors and plantar fascia, gia ua y 

deepening the longi- 
tudinal arch (Fig. 4). 


Fig. 1 

After subcutaneous tenotom3^ Note 
the atrophied gastrocnemius, the thread- 
like heel cord, and pes cavus. 



Diagrammatic drawing, illustrating the development of 
the deformity- shown in Fig. 1. 


This Clinic has 
used both methods of 
lengthening the Achilles 
tendon. Our atten- 
tion was sharply called 
to seven cases oper- 
ated upon within a 
four-year period. Be- 
cause these cases dem- 
onstrated the deform- 
ity just described, a 
serious doubt arose as 
to the virtue of the 
closed operation. 




SUBCUTANEOUS TENOTOMY OF THE ACHILLES TENDON 


421 


Five children were op- 
erated upon for club-foot; in 
one case the deformity was 
bilateral. The ages of the 
patients were four weeks, 
three months, seven months, 
nine months, and twenty- 
four months. Two children 
— one a case of spastic hemi- 
plegia, and the other a case 
of residual poliomyelitis — 
were operated upon at seven- 
teen months. Fig. 3 

A study of the cases Drawing showing slight excursion of the os calcis 

, , , , when the forefoot is flexed, 

revealed no unusual facts. 

All underwent the subcutaneous tenotomy. Each patient was placed in a 
plaster-of-Paris cast from the toes to the groin. The knee was held in 90 
degrees of flexion and the foot in from 90 to 100 degrees of dorsiflexion for 
a period of from six to eight weeks. This method of treatment in general 
corresponded to that used in other clinics. 



Fig. 4 

Roentgenogram showing the deepening of the longitudinal arch .as the result 
of the conditions illustrated in Figs. 2 and 3. 


A review of the texts and literature did not add much to our knowl- 
edge, nor did it give us more definite criteria to guide us in choosing the 
type of operation. We, therefore, sent out a number of questionnaires to 
general surgeons and orthopaedic surgeons, asking for their views on this 
subject. The enthu.siasm, the promptne.-^s of the replies, and the definite 



VOL. XX. NO. 2 . Arnil. IMS 




422 


J. r. HODGEN AND C. H. FRANTZ 


TABLE I 

SuMMARV OF Opinions in Regard to Subcutaneous Tenotomy 
OF THE Achilles Tendon 


Name 

For 

Against 

Questionable 

* Remarks 

LeRoy C. Abbott 

San Francisco, California 


X 


Tenotomj" has not been done for 
many years. 

Carl E. Badgley 

Ann Arbor, Michigan 


X 


Tenotomy has not been done for 
manj’ years. 

George E. Bennett 
Baltimore, Maryland 

X 



Utilized only in very small chil- 
dren. 

Willis C. Campbell 
Memphis, Tennessee 



X 

Utilized in club-foot in infants. 

Fremont A. Chandler 
Chicago, Illinois 


X 


Never employ tenotomy. 

Edward L. Compere 
Chicago, Illinois 



X 

Open operation preferred. 

Frank E. Curtis 

Detroit, Michigan 


X 


Never used this procedure. 

Vernon L. Hart 

Minneapolis, Minnesota 


X 


Should not be done if function is 
expected. 

Melvin S. Henderson 
Rochester, Minnesota 


X 


Open operation preferred. 

Michael Hoke 

Atlanta, Georgia. 



X 

Only employed in infants. 

R. Watson Jones 

Liverpool, England 



X 

Tenotomy rarely indicated. 

Frederick C. Kidner 

Detroit, Michigan 


X 


Tenotomy has not been done for 
twenty years. 

Don King 

San Francisco, California 


X 


Tenotomy never done. 

Samuel Kleinberg 

New York, N. Y. 

X 



Achillotomy, only a small part of 
procedure. 

A. D. LaFertd 

Detroit, Michigan 


1 



Arthur T. T,egg 

Boston, Massachusetts 


X 


Tenotom3’' is never done. 

Paul B. Magnuson 

Chicago, Illinois 

X 



Has never had a case in which 
healing failed to take place. 

Beveridge H. Moore 

Chicago, Illinois 


X 


Not been utilized for years. 

Frank R. Ober 

Boston, Massachusetts 


X 


Not been used for years. 

Charles W. Peabody 

Detroit, Michigan 


X 


Procedure is physiologicalb’ un- 
sound. 

Dallas B, Phemister 

Chicago, Illinois 

X 



Has not seen atrophy in small 
children. 

Edwin W, Ryerson 

Chicago, Illinois 



X 

Tenotomy only utilized as la.st 
resort. 

Arthur Steindler 

Iowa City, Iowa 


X 


Tenotomy has practically been 
given up. 

Philip D. Wilson 

S^ew York, X. Y. 


X 


Xever sever tendon. Staggered 
hcmisection. 

Paul C. Williams 

Dallas, Tc-vas 


X 


Never emploj’cd tenotomy. 


* This cliissifioation is purely arbitrary and is the authors’ reaetion to statements made in th 


received. 

Tini: JOURNAL OI-' ItONU AN'O JOINT Pt 































SUBCUTANEOUS TENOTOMY OF THE ACHILLES TENDON 


423 


opinions expressed denoted unusual interest. Table I is a summary of 
the current feeling in regard to subcutaneous tenotomy. 

COMMENT 

This Clinic has abandoned subcutaneous tenotomy of the Achilles 
tendon because of poor function obtained in seven cases. Stretching of 
the Achilles tendon with the application of a plaster-of-Paris cast and bone 
surgery on the feet are more satisfactory in the end. 

Our own interpretation of the communications which we have re- 
ceived is that the majority of surgeons hold subcutaneous tenotomy of the 
Achilles tendon as an unfavorable surgical procedure which must give way 
to more physiologically sound methods. 

REFERENCES 

Brockman, E. P.: Congenital Club-foot (Talipes Equinovarus). New York, Wm. Wood 
& Co., 1930. 

Calot, Francois: Indispensable Orthopaedics: A Handbook for Practitioners. Vol. II. 
St. Louis, The C. V. Mosby Co., 1915. 

Gallant), W. I.: Subcutaneous Tenotomy of the Tendon of Achilles. Am. J. Surg., 
XXXVIII, 213, 1924. 

Haines, R. W. : The Laws of Muscle and Tendon Growth. J. Anat., LXVI, 578, 1932. 
Jones, Sir Robert, and Lotott, R. W. : Orthopedic Surgerj'. Ed. 2. New York, Wm. 
Wood & Co., 1929. 

Mercer, Walter: Orthopedic Surgery. Ed. 2. Baltimore, William Wood & Co., 1936. 
Moore, J. E.; Orthopedic Surgery. Philadelphia, W. B. Saunders, 1898. 

SoDTTER, Robert: Technique of Operations on the Bones, Joints, Muscles, and Tendons. 
New York, The Macmillan Co., 1917. 

Whit.uan, Royal: A Treatise on Orthopaedic Surgery. Ed. 9. Philadelphia, Lea & 
Febiger, 1930. 

Wright, W. C.: Muscle Function, pp. 95 to 97. New York, Paul B. Hoeber, Inc., 1928. 


YOL. NX. NO. 2. ArniL IMS 



NON-UNION OF FRACTURES OF THE CARPAL NAVICULAR 

BY BENJAMIN E. OBLETZ, M.D., BUFFALO, NEW YORK, AND 
BERNARD M. HALBSTEIN, M.D., CINCINNATI, OHIO 

Irom the Department of Orthopaedic Surgery, * State University of Iowa 

TJie tendency of fractures of the carpal navicular to result in non- 
union has come to be recognized as a distinct characteristic of this frac- 
ture which is one of the most serious and disabling traumatic affections of 
the wrist. Most authorities cite inadequate fixation of the wrist as the 
chief cause of non-union. They also prefer plaster of-Paris splints or 
casts as the means of fixation. There is no such unanimity of opinion 
concerning the position of the wrist during the period of immobilization. 
However, since equally good results have been reported by surgeons who 
favor different positions,^- it is reasonable to assume that the position 
of the wrist during immobilization is not of primary importance. The 
period of fixation also varies, being given at from six weeks to six months 
by various authors.^- Studies of the healing processes in experi- 

mentally produced fractures of the carpal navicular in dogs ® have shown 
that bones of the cancellous type heal more slowly than the long bones. 
This is due largely to lack of subperiosteal callus formation, but it is also 
due in part to the fact that the cancellous reaction is less extensive and 
active than the medullary response in the diaphysis. Experience shows, 
however, that other bones of this cancellous type, such as the bones of the 
tarsus, heal without delay after fracture or osteotomy. It has also been 
found experimentally ® that there is no lytic action of the synovial fluid 
and, therefore, this cannot be considered responsible for non-union. 
Studies of the blood supply of the carpal navicular by injection of the 
arteries with opaque media ® have shown variations in the positions of 
the vessels, giving rise to the belief that these variations are important 
factors in the union of fractured naviculars. 

The authors carefully examined 297 carpal naviculars which had 
been removed from cadavera in the Department of Anatomy of the State 
University of Iowa. The navicular, freed of its soft-tissue attachments, 
is found to be almost entirely smooth. Most of its surface consists of 
articular cartilage, for it articulates with five bones, the radius, the 
lunate, the greater multangular, the lesser multangular, and the capitate. 
There is a narrow rough ridge running obliquely around the dorsal surface 
from the tuberosity on the lateral side to the proximal base medially. In 
this ridge are found the arterial foramina, and it is through these apei tines 

that the bone receives its blood supply. 

In most of the bones examined it was found that the largest foramina 
were situated in the distal half of the bone, particularly near the tubeios 
ity. In 13 per cent, of the bones there were no arterial foramina proxima 
* Service of Arthur Steindler, M.D. 

.94 THE JOUR.VAL OF BONE AXO JOI.VT .SllHOraiy 



NON-UNION OF FRACTURES OF THE CARPAL NAVICULAR 


425 










Dorsal 

Fig. 1 

Ventral 


Type of navicular showing no arterial foramina proximal to the mid-portion or 
“waist” of the bone, at which point fracture is most likely to occur. The proximal 
fragment is totallj' devoid of blood supply in case of fracture. 


to the constricted mid-portion or “waist” of the bone. (See Figure 1.) 
In 20 per cent, of the bones examined there was a single small arterial 
foramen at the ivaist or proximal to it. (See Figure 2.) In 67 per cent. 






Dorsal 


Fig. 2 


Ventral 


Types of navicular showing one arterial foramen at or proximal to the mid-portion. 
The nutrition of the proximal fnigment is proh.ably inadequate where fracture occurs 
through tlie mid-portion of the bone. 


VOI.. XX. NO. 2. APnll. 1P3S 









426 


B. B. OBLETZ AND B. M. HALBSTEIN 




Type of navicular showing two or more arterial foramina proximal to the “waist” 
of the bone. The nutrition of the proximal fragment is probably adequate if 
fracture occurs. 


there were two or more foramina proximal to the waist. (See Figure 3.) 
These findings are significant, for most of the fractures of the navicular oc- 
cur through the waist of the bone. Such fractures would completely in- 
terrupt the blood supply to the proximal portion of the bone in at least 13 
per cent, of the cases, and would definitely interfere with proper nutrition 
of the proximal fragment in another 20 per cent. Therefore, in one-third 
of the instances in which the navicular is fractured through the mid- 
portion the blood supply is diminished to such an extent that necrosis may 
occur, and non-union can then be expected. However, if the immobiliza- 
tion is absolute and prolonged for a sufficient period, the necrotic portion 
will be revitalized by the formation of new blood channels, and union of 
the fragments can then occur. 

Thirty cases of non-union of the carpal navicular were studied. All 
the patients were men in the most active period of life, — from eighteen to 
forty-eight years of age. They came to the Clinic on an average of 
fifteen months after the fractures had occurred. In seventeen cases the 
fractures had not been recognized, and the wrists had received no immobi- 


TABLE I 

Clinical Examination 


Findings 


No. of Cases For Cent. 


Pain in wrist 

Limited flexion and extension 

Swelling 

Weakness of grip 

Tenderness in snuffbox 

Diffuse tenderness 

Arthritic changes 

Associated carpal injuries . . . . 


30 

100 

21 

70 

14 

47 

11 

37 

11 

37 

11 

37 

3 

10 

4 

13 


THE JOURNAL OF BONE AND JOINT SUnGIial 




NON-UNION OF FRACTURES OF THE CARPAL NAVICULAR 


427 


TABLE II 

Roextgexographic Examixatiox 


Findings 


No. of Cases Per Cent. 


Simple fracture line through mid-portion 10 

Comminution 2 

C 3 'st formation 6 

Necrosis: 3 

Pro.ximal fragment 2 

Both fragments 1 

Osteo-arthritis 3 


33 

7 

20 

10 


10 


lization treatment after the injury. In all of the other cases the immobi- 
lization vas woefully inadequate, both as to the type of fixation used 
(slings, adhesive strapping, wood, metal, or plaster-of-Paris splints, etc.) 
and as to the duration of the period of fixation. 

The clinical and roentgenographic findings at the time of the first 
examination in the Clinic are recorded in Tables I and II. 

Only twenty-one of the thirty patients remained for treatment. In 
seven cases conservative treatment, consisting of immobilization in a 
cock-up splint or cast of plaster-of-Paris, was instituted. Operative 
treatment was used in fourteen cases. Excision of one or more fragments 
was the operation of choice prior to the introduction of the drilling opera- 
tion by Beck in 1929. The excision completely alters the arcliitecture of 
the wrist to such an extent that it is indicated now" only as a final means of 
removing the source of pain in comminuted fractures. The drilling oper- 
ation is much simpler and far less mutilating. Table III shows the end 
results obtained by the two types of treatment. 

Summary and Conclusions 

The necessity for prolonged immobilization of the wrist in fractures of 
the carpal navicular in order to prevent non-union is due to the anatomical 
variations in the blood supply to the bone. In 13 per cent, of 297 carpal 
naviculars studied grossly there w"ere no arterial foramina proximal to the 

TABLE III 
Exd Results 


Total Cases Cases Not Cases Not 

Treatment Cases Improved Improved Followed Up 


Conservative 7 1 - 4 

Operative: 14 9 - 3 

Partial c.vcision 4 4 0 0 

Complete excision 0 1 ~ 3 

Drilling 4 4 0 0 


YOL. XX. NO. 2. APRIL ISSS 


428 


B. E. OBLETZ AND B, M. PIALBSTEIN 


mid-portion of tiie bone, the commonest site of fracture. In 20 per cent, 
there was one arterial foramen proximal to the waist, while in 67 per cent, 
two or more foramina were found. Fracture through the mid-portion of 
the bone could, therefore, interrupt the blood supply in about one-third of 
the cases and lead to necrosis. Unless immobilization is absolute and 
prolonged, non-union is liable to develop in these cases. 

Conservative surgery (Beck’s drilling), followed by adequate unmo- 
bilization, is the treatment of choice for non-united fractures of the carpal 
navicular. It is less mutilating than either partial or complete excision of 
the navicular and results in bony union without alteration of the normal 
architecture of the wrist. 


REFERENCES 

1. Beck, A.; Zur Behandlung der verzogerten Konsolidation bei Unterschenkel- 
briichen. Zentralbl. f. Chir., LVI, 2G90, 1929. 

2. Berlin, David: Position in tlie Treatment of Fracture of the Carpal Scaphoid. 
New England J. Med., CCI, 574, 1929. 

3. Bohler, Lorenz : Treatment of Fractures. Fourth English Edition. Baltimore, 
William Wood & Co., 1935. 

4. Hoffmeister W. ; Behandlung der Kahnbeinbriichen und Pseudarthrosen. 
Zentralbl. f. Chir., LXI, 2960, 1934. 

5. Johnson, R. W. : A Study of the Healing Processes in Injuries to the Carpal Scaph- 
oid. J. Bone and Joint Surg., IX, 482, July 1927. 

6. Lexer; Quoted by Bolder, page 88. 

7. Mouchet, Albert; Fractures isolees du scaphoide carpien. Presse M6d., XLII, 
121, 1934. 

8. ScHNEK, Fritz; Die Behandlung der verzogerten Callusbildung des Os naviculare 
nianus mit der Beck’schen Bohrung. Zentralbl. f. Chir., LVII, 2600, 1930. 

9. Soto-Hall, Ralph, and Haldeman, K. 0. : Treatment of Fractures of the Carpal 
Scaphoid. J. Bone and Joint Surg., XVI, 822, Oct. 1934. 

10. Speed, Kellogg: Fractures of the Carpus. J. Bone and Joint Surg., XVII, 965, 
Oct. 1935. 

11. Steindler, a.: Fracture Disabilities of the Wrist. Surg. Gynec. Obstet., LVI , 
487, 1934. 

12. Winkler, Harry, and Miller, O. L.: Fracture of the Carpus. Southern Med. 
and Surg., XCVI, 522, 1934. 


and JOI.NT .SURGKUI 


the journal of nONE 



TENSILE STRENGTH OF THE ANTERIOR LONGITUDINAL 
LIGAMENT IN RELATION TO TREATMENT OF 132 CRUSH 
FRACTURES OF THE SPINE * 

BY ARTHUR G. DAVIS, M.D., ERIE, PENNSYLVANIA 

In a previous paper, submitted for membership in the American 
Orthopaedic Association in 1927 and published in abbreviated form in 
1929, the author stated that the anterior longitudinal ligament could 
be depended upon to remain intact during the period of stress necessary to 
reduce a crush fracture of a vertebra by hyperextension. Grounds for 
this claim consisted of evidence from cadaver dissections and the actual 
use of hyperextension in a series of thirteen consecutive cases. 

Various types of hyperextension haim since been developed. Hun- 
dreds, probably thousands, of fractures of the spine have been reduced by 
hyperextension during the past ten years. So far, evidence of damage 
from hyperextension is not forthcoming. Nevertheless, the fear of over- 
hyperextension still possesses a number of capable and informed operators. 
Since all crush fractures — whether cervical, thoracic, or lumbar — with or 
without dislocation or neurological signs depend primarily upon the 
anterior longitudinal ligament for their reduction, since regardless of 
which of the number of eligible techniques is employed the use of the 
anterior common ligament is inescapable, and since fear, caution, and 
ignorance of the anatomical structures involved have led to distorted 
quotation of method and are now affecting the literature on the spine, it is 
imperative to know definitely what sort of use or abuse the main reducing 
factor, the anterior longitudinal ligament, can withstand. 

This paper is based on the end results of 132 cases of fracture of the 
vertebral centrum seen during the past thirteen years. With but few 
exceptions, the foot-suspension method was used in all thoracolumbar 
cases. In all cases the anterior longitudinal ligament was regarded as the 
check to any possibility of overhyperextension. Misapprehension con- 
cerning the mechanics and anatomy involved have apparcntlj^ led to un- 
warranted fears sufficient to interfere seriously with adequate reduction. 
It is, therefore, a matter of fundamental importance to know, if possible, 
the actual resistance of the ligament to imposed strain versus the amount 
of stress necessary to obtain reduction. 

The difference between the minimal rupture point of the ligament 
and the maximal pull in pounds necessary to reduction will show the re- 
sulting safety factor. The other factor which it is imjiortant to know is 
the degree of elasticity. Since ela.stic jield would probably involve cord 
and root damage, it is important to record the actual elongation per unit 
of imposed strain. 

* Read at the Annual Meeting of the Americ.an .Academy of Orthopaedic Surgeons, 
hos Angeles, Califoniia, January 19, 193S. 


'■OL, XX. xo. 2, ArniL itias 


■129 



430 


A. G. DAVIS 


The following is offered as evidence of the adequacy of the anterior 
longitudinal ligament to withstand with a large margin of safety the stress 
of hyperextension necessary to the reduction of crush fractures. The 
accompanying record also shows that the anterior longitudinal ligament is 
a practically non-elastic membrane, resembling, in its behavior under 
strain, the curve for the reaction of metals, 

METHOD OF MAKING THE TEST 

Coronal sections of the siiine, including the anterior half of the centra 
of seven vertebrae in the region of the thoracolumbar junction, were 
removed from autopsy subjects as they became available. Sufficient 
bone and disc were removed to permit attachment to specially devised 
tapered, ringed, metal rods of an instrument known as a "Universal 
Testing Machine” in the General Electric Test Laboratory, Erie, Penn- 



Fig. 1 

Seven-vertebrae section mounted on “Universal Testing Madiinc • 
Calipers indicate dots used to determine stretch. {Courtesy of Gencrol 
Electric Test Laboratory,) 

sylvania. (See Figure 1.) The remaining cortical shell, anterior longi- 
tudinal ligament, and intervening annulus fibrosus of the specimen v ere 
then lashed securely at both ends to the gearlike rods. Considerable 
difficulty was experienced in preventing the spine from .slipping on t le 
rods. By binding them tightly with succe.ssive windings of heaiy cord, 
it was po.ssible to give the sharp-edged rings or gears a firm bite into t le re 
maining bony shell, thus preventing the attachments from .slipping. ic 

TIIK JOURN'AI, OF UON'K AN'D JOI.VT SirnGI-rn 


CRUSH FRACTURES OF THE SPINE 


431 


cord ivindings were then covered with black tape. The rods were united 
with a telescoping rod introduced between the traction rods to maintain 
a vertical pull. No frictional resistance was introduced by the telescop- 
ing rod; therefore, no allowance is necessar 3 ’' for this factor. The section 
of spine remaining for test consisted of one vertebra and two discs. 

Elasticitj'’ was determined by marking the specimen with India-ink 
dots two inches apart. Calipers recorded the spread of the marks at 
intervals of fifty pounds. 

The testing of the first two specimens was unavoidably delaj^ed for 
three daJ^s, during which time the specimens were kept immersed in salt 
solution and formaldehyde. Allowance must, therefore, be made for 
deterioration. The remaining five specimens were tested within from si.v 
to eight hours of remoi'al. 

RESULTS OP TEST 

Table I shows the record of seven specimens tested as described. 
The average breaking point was 337 pounds. Two unusually strong 
specimens (C. H. and F. J.) are included. Two specimens (V. B. and 
J. G.) deteriorated; these subjects had been bedridden rvith longstanding 
illness. No specimens from females as yet have become available. 


TABLE I 

Results of Tests of Anterior Longitudinal Ligament 


Case 

Age 

(Years) 

Occupation 

Illness 

Duration j 
of 

Illness j 

! 

\ icld in Two- 
Inch Section 

Breaking 

Point 

(Pounds) 

V. B 

44 

Molder 

Occupational 

6 years 

.012 of an inch 

ISO 

J. G 

G5 

Unknown 

emphysema 
Carcinoma of 

2 years 

in 150 pounds 

I GO 

R. B 

54 

LumbeiTnan 

stomach 

Bone sarcoma 

0 months 

.08 of an inch 

230 

H. W 

83 

Unknown 

Fracture at base 

1 day 

in 200 pounds 

3G0 

C. H 

17 

1 

Athlete ] 

of skull with 
cerebral 
bemorrhage 
Septicaemia 

1 week 

.02 of an inch 

550 

F. J 

27 

Molder 

Perforated 

1 month 

in 200 pounds 

4S0 

1. B.. . . 

42 

Machinist 

duodenal 

ulcer 

Endocarditis 

A few liour? 

i 


1 

400 

Average. . . 

47 0 


1 


.037 of an inch 

337‘ 




1 


per 50 pound- 
i over 150 



‘The average breaking point, excluding the two delayed sijcciincns, wa.s 404 ixmnds. 


'■OL. NX, NO. 2, APRIL 1035 





26 


RAGNAR MAGNUSSON 



Case 3. Before operation. 


Unfortunately, 
it ,was impos.sible to 
carry out a personal 
follow-up examina- 
tion of the patients, 
as they live in widely 
different parts of the 
country. Instead, 
they were asked to 
answer a set of ques- 
tions. Of the eight 
patients with certain 
tuberculous osteitis 
of the ischium, seven 
replied to the ques- 
tionnaires. All seven 
of these patients stated 
that both of their hip 
joints were equally 
mobile. It is true 
that lesser degrees of 
restricted mobility 
may have been over- 
looked, but this is 
hardly probable as 
even very small re- 



strictions of mobility as a rule cause discom- 
fort. The longest period of observation was 
eight years; the shortest, one year. Of the 
five patients Avith an osteitis of unspecific or 
uncertain oi’igin, four sent in answers to the 
questionnaires. These patients have also 
been free from symptoms from the hip joint 
since their discharge from the hospital. 

As none of these patients were brought 
under observation until they had reached a 


Fig. 3-B comparatively late stage of the disease, there 

Case 3. Before operation. roentgenograms of the earlier stages. 

This also seems to be the case in previously published cases of tuberculous 
osteitis of the ischium. Thus it is possible to giA'^e only an account of the 
roentgenograms of the later stages of the disease. Both the tuberculous 
and the unspecific forms of osteitis are characterized by AAude-spread de- 
struction, in some cases AAdth abundant formation of sequestra. In all 
of these cases, as Avell as in previously published cases of both tuber- 
culous and unspecific osteitis, the destruction Avas localized to the latera 
pari of the superior ramus or the loiver part of the tuber jschn. In tv, o of t le 


THE JOURNAL OF BONE AND JOINT SURGERY 



CRUSH FRACTURES OF THE SPIXE 


433 


\ 


Skeletal traction 
Plaster collar 
Miner\'a jacket 

Goldthu'ait irons 
Miner%’a jacket 


\ N \ \\ •* 

' V • 


Goldthwait irons 
Three-point jacket 


t -AU. 


Foot suspension 
Three-point jacket 


Hj'perextension in the cadaver, for- 
mal hyperextension has the contour of a 
hockey stick. {Courtesy of P. Blakis- 
ton’s Son & Co.*) 


Showing the several different meth- 
ods of treatment used for simple un- 
complicated crush fractures, depending 
upon the section of the spine involved. 
{Courtesy of P. Blakislon’s Son & Co.^) 


Certain reservations must be made at this 

point. Conditions under tvhich the anterior longi- 

tudinal ligament undergoes horizontal rupture are A'am^n/ri/e 

conceivabl}'- as follows: When suf- ^ 

ficient shear stress is exerted to c>, • 

. ... Showmg the several different meth- 

move the thoracic section horizon- ods of treatment used for simple un- 

tallj^ on a fixed lower section (e.g., complicated crush fractures, depending 

, . . . I I upon the section of the spine involved, 

coal mine cave-ins), or when the {Courtesy of P. Blakiston’s Son &Co.*) 

subject falls from a height back 

foremost, striking a projecting part at right angles to the spine, according 
to the tensile tests in such a case the vertebra would be expected to rupture 
in the mid-centrum and the ligament to rupture transverselj'. Such a 
case actually occurred. The patient was catapulted out of the car and 
landed across a railroad rail, but the ligament was not ruptured. He had 
a fracture-dislocation with paralj’^sis. The spine was carcfullj' hyper- 
extended, and the patient recovered full function. This hj'pere.xtension 
cause of avulsion fracture is extrcmelj’’ rare, occurring onh' once in this 
series. The causative mechanism in this ca.'^e is directly opposite to the 
usual fle.xion. The weight of both ends of the torso is levered sharply 
against the middle, which produces narrowly localized hyperextension. If 
the conditions are thus made sufficiently e.xacting. rupture of the midmost 
portion of the centrum and ligament maj’ be expected. Such a conjunc- 
ture of conditions is, however, highly improbable. 

In the case of the .riiear .stress, if the patient lives, the cord has u.mally 


voi.. XX. xo. 2. Arnii. in.is 




432 


A. G. DAVIS 


The ligament parted in the mid-centrum in each case except in one 
in which it parted at the upper edge. Analysis of this exception forced 
the conclusion that in this case the mounting was at fault, since the break 
occurred at the edge of the cord lashing. 

After three stretch determinations had been made, this part of the 
test was omitted because of difficulty in controlling the slipping of the 
specimen on the rod, the time of suspension apparently having to do with 
the firmness of the hold. It is realized that results from only three cases 
provide meager information; nevertheless, the findings in the three cases 
were surprisingly consistent. 

In no case was a measurable yield recorded up to 150 pounds. From 
150 up, the yield was of the nature of a straight line, — that is, an average 
of .037 in two inches for every additional fifty pounds above 150. 

Against these determinations, the pull in pounds necessary to reduc- 
tion was made on normal living patients of a body -weight ranging from 
150 to 225 pounds. In addition, a typical crush fracture of the first 
lumbar vertebra in a male -weighing 165 pounds was reduced with the 
typical foot suspension regularly used to-day. (See Figure 2.) Chatillon 
balances were interposed between feet and suspension spreader. The 
records show a minimal pull of thirty pounds per leg and a maximal pull of 
forty pounds. Actual reduction required thirty-three pounds per leg, or a 
total of sixty-six pounds. Since the maximal pull required is eighty 
pounds and the minimal breaking strength 160 pounds, the safety factor 
is in the ratio of 2 to 1 at the lowest, 7 to 1 at the highest, and 4 to 1 as 
an average. The relative absence of elasticity indicates that duration of 
suspension has little if any effect in relation to yield of the ligament. 



Fig. 2 

Typical foot suspension and jacket as used for uncomplicated thoracoluinliar 
crush fractures during the past eight years. 

THK JOURN'AI. OF nO.VE AN'O JOIST .SI lU-I.R' 



CRUSH FRACTURES OF THE SPINE 


435 


head, shoulder, and neck section meanwhile is allowed to sag of its own 
weight off the ends of the irons. The Minerva jacket, including head and 
neck as it does, is necessary to retain the reduction. Obviously the head 
requires just sufHcient support for comfort of the patient during applica- 
tion of the jacket. The reduction is accomplished through gravity of the 
head, neck, and shoulder girdle again.st the fixed thoracic spine. 

Fractures of the Cervical Vertebrae 

1. Roll the patient on his back, with padding under the neck. 

2. Send the patient on a stretcher directly to a hospital bed. Appl 3 ’- 
halter traction with the spine in hyperextension, using a five-pound 
weight. Elevate the head of the bed. 

3. Make a neurological examination. 

4. Take an x-rajq using a portable machine. 

5. Make the Queckenstedt test if sj^ptoms indicate the need of it. 

6. Decide whether conservative treatment or laminectomy shall be 
used. 

7. Apply skeletal traction or a plaster collar immediately, depending 
on the condition of the patient. 

8. Check neurological status at intervals. 

Where the intervertebral disc appears to be invoh^ed in a spinal 
fracture — that is, where the intervertebral space is definitely narrowed — 
rupture into the vertebral substance or subdural space is suspected. 
This factor affects the sequence of treatment. If neurological signs can- 
not be explained by fracture, the disc is held responsible until some other 
factor is proved to be the cause. In the absence of neurological signs, the 
nucleus is assumed to have escaped through a fissure or bone space. It is 
thought that the element of traction contained in foot suspension ma}'^ 
mitigate the vertebral atrophy which follows such lesions. No tj'-pical 
bone atroph}'- has been found in the scries presented. 

DISCUSSION OF TREATMENT OUTLINED 

Contrary to recent citations in the literature of foot suspension, no 
roentgenogram is taken during the suspension; nor is the patient watched 
for sjmiptoms or signs of imiiending J)arah^sis or root pressure. There has 
been no reason for this precaution. No anaesthetic is used. No opiates 
are ordinarilj’- used. In cases where immediate reduction bj"- foot sus- 
pension is contra-indicated — where prohibitive complications such as 
shock, cerebral involvement, or multiple fractures interfere — the spinal 
fracture is extended or partiallj' extended on a frame, not Inqierextended, 
or the patient is kept prone with permission to raise hiin.=elf on his elbows 
until he becomes eligible for adequate treatment. 

Where laminectom}^ appears to be indicated, shells are first applied 
with the spine in hjqierexten.sion for eases of thoracolumbar fracture; 
bii'alved plaster collars are used in ea.'^es of cervical fracture. A numlier 
of the patients in the author's series have recovered from var\'ing degrees 


VOL. x.x. xo. 2. .^pnri. in-is 



434 


A. G. DAVIS 


been irreparably damaged by the same horizontal force, rendering all 
treatment futile. Many such fatal cases occur in mines, in heavy indus- 
tries, and in mutilating car accidents. 

OUTLINE OP TREATMENT 

When the spine is normally hyperextended, it resembles in contour a 
hockey stick. (See Figure 3.) Methods of reduction should aim to 
simulate this curve. Variations in anatomy and flexibility alter the 
degree of curvature. When the pelvis swings clear, the 45-degree pull of 
foot suspension tautens the ligament regardless of flexibility or anatomical 
variations. It is useless to attempt to extend all parts of the spine equally. 
The thoracic section merely acts as a fixed point against which the lumbar 
spine is levered. The thoracic spine is relatively immobile. The follow- 
ing outline is based essentially on foot suspension except for high thoracic 
and cervical fractures. (See Figure 4.) It depends upon a taut ligament 
for restoration of form. 

Fractures of the Lumbar and Lower Thoracic Vertebrae 

1. Give first-aid treatment. Eoll the jiatient into the prone posi- 
tion at the site of the fracture. 

2. Take an x-rajL 

3. Make a neurological examination; if there is nerve involvement, 
make a careful analysis. Individualize treatment as outlined under 
discussion. 

4. If there are no paralytic symptoms, reduce the fracture immedi- 
ately by the foot-suspension method, and apply a three-point-pressure 
jacket extending from the clavicle to the pelvis. Do not give an anaes- 
thetic or any narcotic. 

5. On the next day take a check-up roentgenogram. If this shows 
insufficient reduction, remanipulate, using thrust if necessary. 

6. Take another check-up roentgenogram. 

7. Keep the patient recumbent for six weeks, free to change position, 
but not to sit up. 

8. Then shorten the jacket, or, if there has been loss of weight, 
change the jacket. Again check the results roentgenographically. 

9. Allow the patient to be ambulatory for six weeks. 

10. Remove the jacket and take a careful detailed Bucky .x-ray. 
Warn the patient at this time against lifting heavy weights in the stooped 
position. Give postural exercises to develop the abdominal muscles. 

Fractures of the Intermediate Thoracic Vertebrae 

The same sequence obtains in fractures of the mid-thoracic vertebrae 
except that Goldthwait irons are used instead of foot suspension. 

Fractures of the High Thoracic Vertebrae 

These fractures also are reduced on Goldthwait irons. A jMiner\a 
jacket is immediately applied. The torso is supported by the irons, t le 

THE JOURNAL OF DONE AND JOINT SURGERI 



CRUSH FRACTURES OF THE SPINE 437 

TABLE III 

Analysis of Seven Cases With Residual Symptoms 


T 3 ^pe of Fracture 

No. of 
Cases 

S 3 ’mptoms 

Remarks 

Thoracic vertebrae 

1 


Wedged vertebra. Re- 
stricted to work as 
salesman. 

High thoracic vertebrae. . 

1 

Unable to raise both 
arms forward simul- 
taneously. 

Returned to work as 
secretar 3 L 

Lumbar vertebrae 

2 

Lameness of back (1). 
Weak back (1). 

Returned to former oc- 
cupation. 

Cervical vertebrae 

. . 3 

Pain in neck and shoul- 
der (1). 

Shght anaesthesia in 
clavicular region (1). 

Partial numbness in 
lower extremities (1). 



induce the necessary perpendicular structural trabeculations for un- 
restricted weight-bearing. The difference in stress lines between the 
roentgenograms at the end of six weeks and three months is evidence of 
this point. There have been notable exceptions to the above rule of 
thumb. A few unruly patients have gotten up shortly after the initial 
reduction, have continued otherwise under treatment, and have suffered 
no penalty. The explanation for this is well known. The posterior arch 
bears all the weight in a properly hypere.xtended, well-fitting jacket. 
Corpulence, loss of weight, and arch fractures are the chief reasons which 
deter us from earlier activity. 

END RESULTS 

Table II shows the end results in 115 cases which have been followed 
up during the past six months. One hundred and four patients recovered 
and eleven died. Of the 104 patients, forlj'-three were day laborers or did 
heavy work; thirty-three did light or sedentary work; and twentj-'-eight 
were housewives. Seven patients recovered with residual s 3 'mptoms as 
shown in Table III. Of the eleven fatal ca.-^es, seven were fractures of the 
cervical vertebrae and the patients died sliortlj" after fracture; two were 
fractures of the thoracic vertebrae and death followed .'^hortly after frac- 
ture; two were fractures of the lumbar vertebrae and the jiatients died .‘-ix 
months and one j'ear after fracture. At autop.'Jj' destruction of the cord 
was found in six cases of fracture of the cervical vertebrae and in one case 
of fracture of the lumbar vertebrae. 

During the thirteen- 3 'ear period in which the 132 fresh crush fraeturc.s 
were seen, injuries to the intervertebral disc were found in fourteen cases. 
Fusion was done in six of these cases with a questionable result in one case. 


VOL. NX. NO. 2 . APRIL I03S 



436 


A. G. DAVIS 


TABLE 11 

End Results in 115 Cases Followed Ur During Past Six Months 


Returned to Residual 

Cases Former Oc- Symptoms 

Type of Fracture Treated cupation Present Died 


Odontoid process 3 3 0 0 

Cervical vertebrae 27 21 3 7 

Thoracic vertebrae 19 17 2 2 

Lumbar vertebrae 66 63 2 2 


Total 115 104 7 11 


of partial paralysis. Two patients with complete paralysis of the cervical 
spine have also recovered. One recovered completely; another with very 
slight spastic leg signs of a jiei'inanent nature recovered sufficiently to 
return to his former occupation. 

It is becoming increasingly clear that hyperextension is a better 
decompressor than laminectomy for the reason given before, — namely, 
that hyperextension increases all diameters of the intraspinal space by 
removing the impinging bone at the site of the fracture. 


CONVALESCENT CARE 

Roughly, in from three to four months there is a return to formei 
occupation in imparalyzed cases regardless of whether the fractures are 
cervical, thoracic, or lumbar. In those cases where the occupation is 
sedentary or Amry light, the patient returns to work, if work is possible 
in a jacket, in from two to three months. These periods are necessaiily 
somewhat arbitrary for the reason that sufficiently firm callus cannot be 
readily exhibited roentgenographically. Tenderness on deep percussion 
over the iiiAmlved centrum is a more dependable criterion. There is no 

tenderness in a completely recoAmred case. 

The reason for six Aveeks of recumbency is mainly that Avhich pertains 
to fractures of all other parts of the body. According to the general rule, 
physiological rest is guaranteed by recumbency in a jacket AAdiich peimits 
a change of position in the hoi’izontal plane, but disalloAVs sitting oi stanc 
ing. Allowance is always made for the possibility of fractures of the 
accessory processes Avhether or not roeiitgenographic pi oof is picscn . 
While Mensor and others haim shonm these fractures, they arc ordman y 
not subject to expo.sition ; therefore, they must be assumed to be pre.sen 
but hidden by the dense overlying cortical shadow. When present the 
imposition of bod}'" Aveight aboAm the fracture induces slieai sticss a\i i 
possible sequelae of excess callus and pressure radiculitis. ^ „ 

It is considered important to institute ambulatoiy tieatmen a 
end of six weeks. Again by analogy, it is assumed that bone differentia- 
tion has occurred. The A'ibrational influence of Avalking then ser\cs 

THE journal of RO.VE AND JOI.VT fiUROEKV 


CELLULOSE-COMPOUND CASTS USED IN THE TREATMENT 

OF ARTHRITIS * 


BY ROBERT J. JOPLIN, JI.D., F.A.C.S., BOSTON, MASSACHUSETTS 
Assistant in Orthopaedic Surgery, Harvard Medical School 

From the Clinic of the Robert Breck Brigham Hospital, Boston 

A light-weight, durable, waterproof cast, which will transmit x-rays 
Mthout obscuring shadows, has long been desired to replace plaster-of- 
Paris. Fortunately, a recent discovery ‘ has made available to the medi- 
cal profession a cellulose compound long used in industry. A verj'^ con- 
venient product is now available in the form of a roll of unbleached cotton 
sheeting, cut on the bias in two-inch and three-inch widths, ten jmrds 
long, impregnated with solvent, and contained in a hermetically sealed can 
ready for instant use. 

Briefly summarized, the physical and chemical properties of this 
compound belong to the realm of colloidal chemistry in contrast to crys- 
tallization of plaster-of-Paris. Boric acid and a safety type of pyroxylin, 
containing only 12 per cent, nitrogen dissolved in acetone, form the adhe- 
sive constituents. When the acetone has evaporated, the hard cast is no 
more inflammable than wood. It is much safer to handle when wet than 
collodion. 

Although when applied to the bare skin no irritation has been ob- 
served, usually the cast is applied over a layer of stockinet or sheet wad- 
ding. Hardening is slower than it is when plaster-of-Paris is used, but 
after forty minutes the cast is quite firm. Drying maj" be facilitated b}^ 
using an ordinary radiant-bulb lamp and plenty of ventilation. Verj" 
little objection to the odor of acetone, which disappears with drjnng, has 
been expressed by any patient. Although rubber gloves are usually used 
by the operator, they are by no means necessary, since a little petrolatum 
on one’s hands prevents the bandage from sticking to the fingers. At- 
tention must be called to the fact that, if the cellulose-compound bandage 
is stretched and applied tightly, there will be a certain amount of shrink- 
age upon drjnng, but this shrinkage is not appreciable if the bias bandage 
is carefully applied without its width being narrowed. Also, C3'linders tend 
to curl slightly unless an even number of laj'-ers are applied with alter- 
nate layers reversed. 

Because of certain outstanding advantages over plaster-of-Paris — 
mainlj’- lightness in weight and some resiliencj' — fortjMwo cellulose- 
compound casts have been applied on twcnt3'-four patients with arthritis, 
with results which were favorable be3'ond expectation. A desire to have 
all plaster-of-Paris casts replaced b3'' cellulose-compound casts was 
quickl3' sensed in the wards of arthritic patients soon after one or two 

* Read before the Boston Ortliopaedic Club. January 10. 1P3S. 


'"OL. XX. NO. 2. APRII, 103S 


•439 



438 


A. G. DAVIS 


Thirty cases of old fracture with disabling symptoms, which had been 
treated by others, were also seen. Fusion was done in thirteen of these 
cases. Several of these patients had some residual disabling symptoms 
following the fusion. Most of them, however, have returned to their 
former occupations without disability. No exact analy.sis of end results 
in these fused cases has been attempted. 

SUMMARY 

There is more certainty regarding return to former occupation in the 
average uncomiDlicated crush fracture than there is in the case of fracture 
of a long bone. Reductions are more complete, union more certain, and 
malunion well nigh impossible. There is no threat of soft-part inter- 
position. 

At present the complete treatment of a simple crush fracture is less 
time-consuming and involves less work than most long-bone fractures. 
Present practice allows the dependable patient to leave the hospital in a 
day or two to spend six weeks recumbent at home. Three or four after- 
calls suffice to restore him to his former occupation. This sequence is 
rapidly becoming average. 

Tensile-strength and elasticity tests indicate competence of the an- 
terior longitudinal ligament far beyond the necessary strength required 
for reduction by hyperextension. Additional proof of adequacy is 
afforded by the 132 cases in which reduction was accomplished without 
evidence of damage. 


REFERENCES 

1. Burns, David: Introduction to Biophysics, p. 214. London, J. & A. Churchill, 
1929. 

2. Davis, A. G.: Fractures of the Spine. J. Bone and Joint Surg., XI, 133, Jan. 1929. 

3. Deaver, j. B,: Surgical Anatomy of the Human Bod}^ Ed. 2. Vol. II, p- 328. 
Philadelphia, P. Blakiston’s Son & Co., 1926. 

4. Lovett, R. W. ; Lateral Curvature of tlie Spine and Round Shoulders. Ed. 3, p. 32. 
Philadelphia, P. Blakiston’s Son & Co., 1916. 

5. Mensor, M. C.; Injuries to the Accessory Processes of the Spinal Vertebrae. J. 
Bone and Joint Surg., XIX, 381, Apr. 1937. 


the journal of bone and joint eurgerv 



TUBERCULOUS OSTEITIS OF THE ISCHIUM 


27 


cases of tuberculous 
osteitis (Cases 3 and 
5), the superior ra- 
mus alone was the 
seat of the process: 
and in three cases 
(Cases 2, 7, and S), 
the destruction af- 
fected both the tuber 
ischii and the su- 
perior ramus and 
reached the level of 
the edge of the ace- 
tabulum. In the re- 
maining cases (Cases 
1, 4, and 6), the 
process was princi- 
pally localized to the 
tuber ischii and the 
adjoining parts of 
the superior ramus. 

Also, in two of the 
cases of unspecific 

osteitis (Cases 10 and 13) the destruction reached 
the acetabulum. Although in several of the 
cases juxta-articular foci existed, they do not 
seem to have had the same catastrophic influ- 
ence on the joint as do those juxta-articular foci 
which are situated in the collum femoris, in the 
greater trochanter, or within the ilium. As has 
been pointed out, there has been no case in the 
present series in which a coxitis has developed on 
the basis of an osteitis of the superior ramus. 

One may thus consider it especially character- Case 3. After operation, 
istic of this form of osteitis, whether of tubercu- 
lous or of unspecific origin, that it does not lead to coxitis. Osteitis of 
the superior ramus of the ischium does not show any tendency to ascend 
and thus break through into the hip joint. This is much more difficult to 
explain, as in cases of co.xitis there is not infrequentlj’’ found a destruction 
descending from the hip joint along the superior ramus of the ischium. 
As recently performed vascular anatomical investigations have shown-, 
it does not seem possible, in any case, to explain these facts as being due 
to the blood supplj-^ within the ischium and the hip joint. 

In the earliest stages of tuberculous osteitis of the ischium — that is, 
before anj'^ objective clinical or roentgenographic sjnnptoms have de- 
veloped — all those states of ill-health which are generally classified under 

VOL. XX. NO. 1. JANOARY IB3S 




Fig. 4-A 


Case 3. After operation. 


440 


R. J. JOPLIN 



Fig. 1 

Demonstrating the amount of correction obtained by cellulose-compound 
cast at the end of three weeks. 


patients experienced the change in their retentive apparatus. This cast 
lias been employed in treating all kinds of arthritis with consistent ap- 
proval of its use in each type. 

For example, in rheumatoid arthritis in those patients under treat- 
ment for correction of deformities after the acute stage of the disease had 
become quiescent, where plaster-of-Paris had been tried numerous times 
unsuccessfully, cellulose-compound casts were tolerated with much less 
discomfort. The most outstanding example of this occurred in a young 
woman, twenty-four years of age, whose rheumatoid arthritis had begun 
at the age of twelve years. On admission to the hospital, examination 
revealed involvement of practically every joint in the body. She had 
flexion deformities of both knees. Plaster-of-Paris cylinders had been 
.applied several times for the purpose of correction. Each time, the pa- 
tient complained of such severe discomfort that, during her three-year 
stay in the hospital, she could not tolerate any plaster cast on her legs for 
over fifty-six hours at a time. On November 11, 1937, two cellulose-com- 
pound cylinders were applied to the lower extremities. After four days, 
these casts were cut back of the knees in such a way that throat sticks 
eould be used for wedging the cast open posteriorly. The patient stated 
that she was able to move about Avith less discomfort with them on than 
■off. At the end of three weeks, twenty-six tliroat sticks had been inserted 
back of each cylinder (Fig. 1). At that time the cylinders Avere removed 
and new ones Avere applied. Wedging Avas started again. After four 



Fig. 2 

Cellulose-compound cylinder applied after the left knee had been e.xtendcd. 

THE JOURXAl. OF nON'F. AXD JOINT SURGERA 




CELLULOSE-COJIPOTJND CASTS IN TREATMENT OF ARTHRITIS 441 



Fig. 3 

Cellulose-compound cylinder shoim in Fig. 2, removed to show detail. Note 
the extreme thinness. A longitudinal strip, the width of the patella, has been 
cut out anteriorl 3 \ 

weeks more, the knees were completely extended. The patient stated 
that she could tolerate these casts because of their extremely light weight 
which allowed her to move about freely in bed, whereas the plaster-of-Paris 
casts had always been so heavy that she had never been able to move about 
without assistance. 

In the treatment of both bed and ambulatory patients with arthritis, 
cellulose-compound cylinders have proved a very valuable adjunct to 
physical therapy. A patient who was bedridden with rheumatoid arthri- 
tis had ankylosis of both hips and of the right knee in such a position that 
he was unable to sit or to stand. Arthroplasties of the left hip and knee 
were performed. Physical therapy was started in the Hubbard tank as 
soon as the wounds had healed, but the patient complained of severe pain 
in the left knee joint. Therefore, all active motion had to be stopped 
until a cellulose-compound cylinder was applied (Figs. 2 and 3). With 
this waterproof, light-weight support, painless exercise under water was 
carried out regularly and effectively (Fig. 4). Within a few weeks’ time a 



Fig. 4 

ncmonstraliiig tlio .actual use of tho cclluloso-oompouiul cvliiuicr for uiifior- 
watcr cxcrciiTs in tho Hubbard tank. 

'■"I. XX. NO. j. 


loas 




442 


R. J. JOPLIN 



Fig. 5 

Showing the case with which the patient can lift the leg and cast against 
gravity. 


partial weight-bearing walking caliper was fitted. The patient was then 
able to begin walking again after a lapse of ten years. He wore the cellu- 
lose-compound molded cylinder inside his walking caliper. 

In a case of septic arthritis of the knee 
with secondary osteomyelitis, it seemed 
impossible to apply a plaster-of-Paris cyl- 
inder which would last more than a few 
days before it would become contaminated, 
discolored, and malodorous from the pro- 
fuse discharge. Nevertheless, a plaster-of- 
Paris cast was made, using steel bars to foim 
struts over windows necessary for dress- 
ings. This arrangement was so cumber- 
some and heavy that the patient had to 
lift his leg with his hands whenever he moved 
in bed until a cellulose-compound cylinder 
was substituted. The patient was de- 
lighted because of the ease with which le 
could move about with the use of his own 
leg muscles. The cast was cut dov n the 
center of the front (since bivalving is un- 
necessary with such elastic material) to 
permit its occasional removal for dressings. 
It did not absorb purulent, malodorous 
sinus discharges, and it did not become 
boggy and soft. The patient would very 
proudly lift his leg into the air to demon- 
strate his new achievement, and incident- 

THE JOUnN'At. OF nO.VE AN'O JOI.VT Sl-RGEIl 



Fig. 6 

^ Anterior view of a pair of cellu- 
lose-compound walking cylinders. 
Note the neat appearance which 
is made possible by the elasticity 
of the material which permits it to 
conform to the parts to bo 
protected. 



CELLULOSE-COMPOUND CASTS IN TREATMENT OF ARTHRITIS 443 

ally benefited by this exercise (Fig. 5). 

After wearing this cast for four weeks, 
the patient was permitted to start 
walking with a non-weight-bearing 
Thomas-band walking splint with a 
patten bottom. With this splint he also 
wore a light-weight walking cylinder of 
cellulose compound, which gave ade- 
quate protection to the sensitive knee 
joint. 

In treatment of aged patients 
with osteo-arthritis, and likewise in 
the treatment of ambulatory patients 
vdth arthritis of the knees whose joints 
are quiescent when the patients are 
recumbent but become swollen and 
painful on attempted walking, so- 
called walking cylinders have been 
used with excellent results. Previ- 
ously, molded plaster-of-Paris pos- 3 tr$SfhooLX^dded ojf Serlide to 
tenor slabs were used which were facilitate lacing, 
similar in shape to so-called "ham” 

splints. Such splints, however, gave relatively little support to the lateral 
ligaments of the knee joint as compared with the new cylinders depicted 
here. The resiliency of the cellulose-compound cylinder permits removal 
and reapplication without destroying the shape and accurately fitting 
qualities. Furthermore, the cylinders easily remain in place and do not 
slide down onto the ankles of the patient during walking (Fig. 6). The 
actual weight of each of these casts, complete with buckles and straps, is 
about ten ounces. 

From the standpoint of economy, in the treatment of Strumpell-Marie 
arthritis involving not only the spine but rib articulations, shoulders, and 
hips, cellulose-compound jackets, constructed over a torso such as is used 
for the making of molded leather jackets, can be furnished for about one- 
quarter of the cost of the leather jackets. (See Figure 7.) The molded, 
tempered back steels can be incorporated in the cellulose-compound 
jacket just as in a leather one. The finished product is not onl 3 ’^ much 
thinner, lighter, and cooler, but it tends to hold its shape better because 
it is tougher and will not deteriorate after excessive perspiration in hot 
weather. Incidentally, one of our patients had a rather marked .st met ural 
scoliosis as well, which also received some support from this jacket. 

Futhermore, when a Bcihler walking iron is incorporated in a cel- 
lulose-compound cjdinder, the iron docs not rust, but remains suitable 
for use on another patient. 

1. TaonxDiKE, Augustus, Jr., .vnd G.^rrev, tV. E.: A Useful T\-pc of Light, Water- 
proof Cast. Preliminary Report. Xcw England J. Med., CGXVIII, 20."), JP.'IS. 

VOL. XX, XO. 2, Arnil. I93S 



Fig. 7 



THE NEUROLOGICAL ASPECTS OF INJURIES TO THE SPINE * 


BY HOWARD C. NAFFZIGER, M.D., SAN FRANCISCO, CALIFORNIA 
From the Department of Surgery, University of California Medical School 

It may be granted at once that destructive damage to the spinal cord 
cannot be repaired, that no regeneration occurs, and that destructive 
lesions are in no way amenable to surgery. A number of pertinent ques- 
tions, however, may be asked, althougli there may be some debate over 
the answers. For example, one may inquire whether the factor of con- 
tinuing compression of the cord by displaced bone is important, and par- 
ticularly whether or not the relief of such pressure will aid in restoring 
function. Again, in the presence of displaced vertebrae, particularly 
in the cervical region, with evidence of complete interruption of function 
in the cord, is it possible that restoration of the normal alignment of the 
spinal canal will permit any return of function? If there is evidence of an 
incomplete lesion of the cord, can surgical intervention minimize the 
effect of the injury and permit a better outlook for the future? How often 
is hemorrhage a factor in causing paralysis? If intra-medullary hemor- 
rhage is present, what can be accomplished by surgery? Under what 
conditions is surgical intervention desirable? 

These are some of the questions which recur. Tlie wi'iter does not 
believe that answers by neurological surgeons of experience would vary 
widely, although there is little doubt that earlier in their careers most 
of them were much more optimistic about the possibility of accomplish- 
ment by operative treatment than tliey became later. In general, any 
very great enthusiasm for operation in more than a small percentage 
of cases is confined to the less experienced. In this regard, the author is 
not speaking of injuries to the lower spine, below the level of the first 
lumbar vertebra, in which the situation is altogether different. There 
we are dealing with nerves of the can da equina, below the level of the 
spinal cord. 

Actual compression of the spinal cord arises from narrowing or dis- 
tortion of the spinal canal, or enlargement of the cord itself from intra- 
medullary hemorrhage or swelling. In such instances it is generally felt 
that maximum recovery of the cord cannot be expected unless this com- 
pression is relieved. Possibly there is an element of truth in this state- 
ment. Usually, however, there seems to be an entirely unwarranted 
optimism as to the possible accomplishment. Continued compre.«sioii 
of the cord can conceivably cause a local ischaemia and produce sccondaiy 
changes in addition to those primarily caused by the trauma. In a con 
which has been damaged but not destroyed, can continued pressure pro- 
duce further changes? In this connection, the writer believes that an 

♦ Eead at the Annual Meeting of tlie American Academ}' of Orthopaedic Surgeons, 
Los Angeles, California, Januarj' 19, 1938. 


444 


the JOUnXAL OF 


noN'E Axn JOINT suitoiatv 



NEUROLOGICAL ASPECTS OF INJURIES TO THE SPINE 


445 


analogy can be drawn between the brain and the cord. In the experi- 
mental laboratory some time ago we conducted a large number of animal 
experiments in which the effects of localized pressure on the brain were 
studied. In these animals localized compressions of the brain were 
produced in various ways. In one series localized depressed fractures 
were caused by means of a regulated blow; in another series depressions 
of an equal depth were produced at operation by the insertion of a small 
object between the dura and the brain, without subjecting the area to a 
blow. These experiments led to the unmistakable conclusion that the 
pathological changes associated with these localized lesions arose from 
the manner of their production rather than from the lesions themselves. 
Whatever pathological changes were present in the brain were caused 
by the force of the original trauma. Localized compression produced in 
such a way that there was no immediate damage to the brain, even 
though such pressure continued for a long time, produced no pathological 
alterations other than a condensation of tissue, which promptly returned 
to normal when the compression was relieved. Continued pressure upon 
a localized area of the brain did not lead to permanent circulatory changes, 
degeneration, cystic formation, or any other discoverable process. 
While, so far as the author knows, similar experiments have not been 
carried out on the spinal cord, it is not easy to give credence to the idea 
that a compression, the result of an acute displacement, would be likely 
to cause symptoms of compression of the cord. It is far more probable 
that organic damage to the cord was caused by trauma at the time such 
displacement occurred. While there may be other good and sufficient 
reasons for securing a reposition of the vertebrae, one should not expect 
that this procedure will materially influence the signs that indicate faulty 
function of the spinal cord. 

If we are correct in assuming that neurological disturbances following 
injury to the spine are caused by organic alterations in the cord, rather 
than by blocking of ph3’^siological impulses from pressure on the cord, 
under what conditions may surgical intervention be helpful? First, let 
us consider that group in which function of the .spinal cord is complcteh' 
lost below the level of the injury. 

Recently, and deservedly, much has been written on the handling 
and transportation of the patient who has just received an injur3’’ to the 
spine. When such a patient enters the hospital, the first con.sideration is 
to determine the presence and severit3'^ of the injuries to tlie spinal cord and 
its nerves. The picture of complete paral3'^sis from injur3" to the spinal cord 
is well known, and the flaccid paral3’^sis, absence of reflc.xes, deep sensor3'^ 
loss, and paral3"sis of the sphincters are rcadil3' determined. If tlie motor 
parab'sis is complete and the reflexes are lost, the briefest of examinations 
will determine the upper limit of the sen.';or3’ paral3"sis. Below this iqipcr 
level we wish to know if the scnsor3' loss is complete. If the examiner will 
step to the foot of the bed and forcibh' flex one of the patient’s tocj? and 
compress it in such a manner as to cause severe pain, and if the patient 

VOL. XX. NO. 2. ArUIL 103S 



446 


H. C. NAFFZIGER 


perceives no sensation wliatever, the sensory loss may be considered to be 
complete, for otherwise deep sensibility and sense of pain would remain. 
If the patient perceives some sensation from this test, the interruption 
of the cord is incomplete. This we consider the most practical and in- 
formative part of the sensory examination. When the sensory loss is 
incomplete, a more detailed study is required. 

Given complete interruption of function, the question may be raised; 
“Is this caused by complete division of the cord, or may it arise from a 
physiological interruption which may be temporary and dependent upon 
such factors as contusion and hemorrhage, much of which may resolve 
and permit a return of function?” In this connection, the writer may 
say that he has yet to see a patient who exhibited a flaccid paralysis with 
an absolutely complete motor and sensory loss and paralyzed sphincters, 
which persisted for twenty-four hours after injury, show recovery other 
than that limited to a few segments about the level of the injury. Addi- 
tional information is gained from roentgenographic studies of the spine, 
both anteroposterior and lateral projections. Occasionally the deformity 
may be so great as to indicate a complete shearing off of the intraspinal 
structures. Spinal puncture will determine the presence or absence 
of blockage of the spinal canal, although in the writer’s experience, when 
there is clinical evidence of complete interruption of the cord, this test 
has not led to improvement in the treatment of these severely injured 
patients. Given such a picture, the patient’s comfort and the prevention 
of such complications as decubitus and urinary infections, are particular 
responsibilities. The author believes that proper use of an air mattress, 
inflated just sufficiently to permit its ready conformation to the contours 
of the patient, is of the greatest aid. With the patient on an air mattress, 
the knees may be moderately flexed with several pillows beneath them, 
giving support under the lower half of the thighs, the knees, and along 
the calves down to the ankles. The extremities should be so supported 
that the heels clear the bed, and pres.sure sores upon them can be avoided. 

A cradle over the lower extremities to sustain the weight of the bedclothes 
is in order, and a lamp may be provided, if necessary, to maintain the 
proper temperature. With such an arrangement, clean dry sheets which 
are kept smooth, and the use of alcohol and camphor on the skin, the 
patient can be adequately protected against bed sores. In our experi- 
ence, catheterization and indwelling catheters, even under the best 
conditions, do not prevent infection of the urinary tract. The writer 
believes that there can be little doubt that suprapubic cystotomy with 
drainage is the procedure that has most to recommend it. 

The skeletal injury receives the next consideration. Fixed 
cannot be laid down, and generalizations are difficult. If the severity o 
the injury to the cord is fully appreciated, it is obvious that the treatment 
of the skeletal injury itself should have as its goal the future comfort o 
a paralyzed patient rather than the more ambitious aim of re.stoiing t m 
skeletal structures to a condition satisfactory to a person who would 

THE JOUR.VAL OF BO.VE AXH JOINT SUnC.r.R'i 



NEUROLOGICAL ASPECTS OF INJURIES TO THE SPINE 447 

later be ambulatory. It may be mentioned here that complete lesions 
of the cord, particularlj'- from injuries to the thoracolumbar spine, may 
be compatible with indefinite periods of life and a self-supporting economic 
status. The author has a number of such patients who have properly 
arranged wheel chairs and seating arrangements, and are carrying on 
the occupations of watch-maker and jeweler, stenographer, and radio 
repairer. In this group of patients, the recognition of the severe nature of 
the injury, treatment designed to spare them complications, and the 
proper handling of the psychological situation, with an early effort to 
restore to them some earning capacity, are the factors which we should 
emphasize. 

Although the subject of cervical injuries will be covered by others, the 
writer would like to indicate here that the complete cervical injuries are 
so grave and the expectation of life is so short that the plans which apply 
to patients with injuries lower in the spine are not applicable. 

Let us next consider the group of spine injuries in which varying 
degrees of impairment of nerve function are present, without complete 
paralysis. Given a spine injury with incomplete paralysis, it has been our 
experience that the improvement which the patient shows is usually far 
greater than might have been surmised at first, and that this improve- 
ment continues over a surprisingly long time. Perhaps many of the 
enthusiasts for operatii^e treatment have formed their judgments from 
contact with these incomplete lesions and have attributed a striking 
impi'ovement to the activities of the surgeon rather than to the natural 
processes active in repairing contused tissues. Certain factors are used 
as guides to treatment in injuries at various levels of the spinal cord, 
leaving injuries to the cauda equina out of consideration. If the motor 
and sensory paralyses are incomplete, the earliest observations of the 
patient should be thorough and detailed. Signs which are altering and 
paralysis which is increasing lead to very different judgment as to treat- 
ment than if such signs are stationary or showing a tendency to regre.ss. 
Spinal puncture, with the determination of the presence or absence of 
blockage in the canal, is in order. Surgical procedures of one type or 
another are far more often required than in the complete lesions previously 
described. In the cervical region, this incomplete damage to the cord 
frequently manifests a predominantly unilateral injury, with a Brown- 
Sequard paralysis and an associated injurj’^ to roots of the brachial ple.xus. 
It is our feeling that, in these cervical injuries, restoration of the align- 
ment of the vertebrae and restoration of the spinal canal are to be under- 
taken. Although our experience with such traction is very limited, it 
would seem that skull traction bj^ some such method as that dcvi.«ed by 
Coleman and Crutchfield is mechanicall3'’ the most advantageous and 
satisfactoiy. The use of a head halter has not met with anj- high degree 
of enthusiasm either on the part of the patient or of the surgeon, and i.s 
certainty trjdng and unsatisfactorj-. The helpfulness of a direct attack 
on the cervical cord tyv lamincctonn' maj' be serioush' questioned. This 


VOL. XX. XO. 2. -XPRII. 103S 



448 


H. C. NAFrZIGER 


operation may be desirable in rare instances in which the spinous processes 
or laminae themselves need removal, but helpful intradural procedures 
would be most unusual to say the least. Exception may be made when 
there is evidence of increasing paralysis. At lower levels in the spine, 
patients in whom incomplete lesions of the cord show inci'easing signs 
should be operated on. Compression of the dural canal by injured lami- 
nae should be relieved. If there is blockage of the spinal canal, as indi- 
cated by the Queckenstedt test, Ave believe that opei'ation is in order, 
even though the signs of paralysis are not increasing; laminectomy, open- 
ing of the dura, and treatment to be detei’mined by the conditions found 
should be carried out. It is in this group that careful consideration of 
and appropriately directed treatment for the skeletal condition itself, 
either by bone graft or by more conservatiAm measures, is in order. 

If neurological signs are present in injuries of the lumbar spine, either 
AAuth or AAuthout eAudence of a complete lesion, it has been our practice 
to adAuse laminectomy at as early a time as the general condition of the 
patient aauII permit. Although in injuries of the first lumbar A’^ertebra 
the tip of the spinal cord — the conus medullaris — may be irreparably 
damaged, the nerAms of the cauda equina .should be put in the best condi- 
tion to permit a return of function. We liaAm had the experience of haA^- 
ing patients Avho haAm been brought to us AAuth injuries of the loAA^er lumbar 
spine, in AA^hom the earliest neurological findings had indicated incomplete 
damage, shoAV progressive neurological impairment and, at the time of 
laminectomy, aa-c haAm found the filaments so matted together by scar 
and adhesions that little could be accomplished by the surgeon. We 
believe that earlier attention Avould haAm preAmiited such a matting to- 
gether of the filaments and permitted a better outlook. 

In summing up the factors AAdiich influence one’s surgical judgment, 
certain points may be emphasized: 

It is of primary importance to determine the completeness of tlm 
neurological lesion. With eAudences of a complete lesion AAdiich persist for 
twenty-four hours after injury, surgery is probably of no benefit and 
permanent paralysis is expected. 

In incomplete lesions combined AAuth evidences of obstruction of the 
spinal canal, appropriate measures should be instituted to restore the 
spinal canal or laminectomy should be done to remoAm pressure. 

Judgment of the patient’s future as regards paralysis is necessary 
before any decision can be made. With an outlook for permanent paral}’’- 
sis, the need for any major surgery is most infrequent. 


the JOUIINAL OF BONE AND JOINT SUIlOI.in 



AN ACCESSOR!" TABLE TOP WHICH ELIMINATES GUESS- 
WORK FROM EXTRA-ARTICULAR INTERNAL FIXATION OF 
FEMORAL-NECK FRACTURES 

BY E. W. CLEARY, M.D., SAN FRANCISCO, CALIFORNIA 

When the author first undertook to do internal-fixation operations 
with the thigh in a position of right-angled flexion,^’- he was impressed by 
the lack of an effective mechanism for holding the limb in this position. 
He then undertook to devise a mechanism which would serve this purpose. 
The accessory table-top assembly, which is the result of this endeavor, has 
passed through a series of models and changes over an interval of several 
3 ’^ears. It has been used for twenty-five or more fixation operations. 
Its use greatly facilitates the operation, shortens the operating time, and 
gives the surgeon accurate guidance as to point of insertion, direction, 
and depth in the placement of the internal-fixation device, whether it be 
bone graft, screw, single or multiple nail, or locking bolt. The simplifica- 
tion and standardization of x-ray technique effected bj’' the mechanism 
not only minimizes the strain on the patient, but lessens the tax on the 
time and patience of the surgeon, the roentgenologist, and the operating- 
room staff. 

The device enables the surgeon to accomplish secure and accurate 
fixation by bringing precision and accuracy into three steps of the opera- 
tive procedure. It provides for: 

1. Secure immobilization of the reduced fracture of the hip in trac- 
tion in a position of right-angled flexion of the tlfigh and in anj^ degree of 
rotation and abduction or valgus desired. 

2. Accurate x-ray localization in vertical and horizontal projections 
of the position of the fractured femoral neck and head with respect to tlie 
table top over which the hip is held immobile. 

3. Accurate and easy transfer of the localizing information supplied 
by the roentgenograms into the aseptic field of operation. 

DESCRIPTION OF THE APPARATUS 

A traction leg holder fFigs. \,A and 3, A) is fixed to an x-ray jierme- 
able table top (Fig. 1,B) which has a ca.s.sette tunnel (Fig. 1,CL A lifting 
disk (Fig. 3,D), acting on the inner threaded shaft of the leg holder (Fig. 
3,F), supplies the desired amount of traction. The degree of valgus 
increases proportionatelj’^ to the extent that the buttock on the injured 
side is lifted. The leg, tied in the holder, is placed in the desired rotation 
and, after sufficient traction has been applied, is locked In- a turn of tlie 
locking disk (Fig. 3,F). This accomplishes the first step. 

Directing guides (Fig. 1,U and //) indicate the po.dtion of the tube 
center and the direction of the ray for horizontal (Fig. 4) and vertical 
(Fig. 5) views. 

•tt't 


vot,. XX. xo. 2, APIUI. 1P3S 



450 


E. W. CLEARY 



A: Leg holder 
B: Table top 

C: Horizontal cassette tunnel 


Fig. 1 


Z: vertical cassette tunnel 
G and H: Directing guides for 
the x-ray 


Plotting fields, of a substance which is not permeable to the x-ray, 
laid out on the intervening surfaces of the cassette tunnels appear on tlie 
negative as shown in Figures 4 and 5. In addition to the lines which 
form one-inch squares, there are lines laid out at angles of 10, 20, and 30 



Fig. 2 

Hip in position and immobilized after local anaestlietization and manipulative 
reduction. 

THE JOUKNAL OF HONE AXD JOINT SUllGEnl 



FIXATION OF FEMORAL-NECK FRACTURES 


451 


degrees, so that the angle at 
which the central axis of the 
neck lies in relation to the 
double center line of the plot- 
ting field, or its parallels, is 
directly indicated. Superpo- 
sition of the shadow of the 
bone over the shadows of the 
localizing plotting fields pro- 
iddes accurate localization, 
thus accomplishing the second 
step. 

There are three steriliz- 
able parts utilized in carrying 
out the final step; a post 
shield (Fig. 3,F)) a horizontal 
plate (Fig. 3,L), and a pointer 
instrument (Fig. 3,il/). The 
post shield proiddes a sterile 
cover for the post of the leg 
holder. The horizontal plate 
locks securely to the table top, 
providing a large sterilized 
surface. Over the central por- 
tion of this plate the base of 
the pointer instrument slides 
in a slot. It may be posi- 
tioned and locked, vdth its center in the vertical plane in which the axis 
of the femoral neck is shown by the horizontal roentgenogram (Fig. 4). 
The pointer instrument (Fig. Z,M) is slid into position after the lateral 
surface of the trochanter is exposed through the incision. This pointer 
instrument consists of an adjustable post mounted verticall 3 '' in the center 
of the base plate (Fig. 3,»S). The head of this instrument is composed of 
two graduated disks, so mounted and attached to the vertical post S 
that a pointer pencil (Fig. Z,N), sliding in a channel in the head, can be 
adjusted at whatever level and angle are desired to “find ” for the surgeon 
the position and direction of the central axis of the neck of the femur. 

The radial graduations on the vertical and horizontal disks, like tlie 
angle lines of the localizing plotting fields sliown in the roentgenograms, 
indicate 10, 20, and 30 degrees in the horizontal or vertical views, so that 
the surgeon maj’-, by reference to the roentgenograms, verj' quicklj" and 
easily set the pointer pencil to mark the spot where the central axis of the 
neck passes through the trochanteric cortex. Having marked this spot 
on the bone with drill or chisel, the operator maj* then make a second 
adjustment of the disks, so that the pointer pencil exact h- parallels the 
axis of the femoral neck. When this .cceond adjustment has been made. 



Fig. 3 

A: Leg holder 
D: Lifting disk 
E: Threaded inner shaft 
F: Locking disk 
O and P: Pointer head 
L; Horizontal metal plate 
M: Pointer instrument 


N: Pencil 
R: Post 
S: Base plate 
T: Slide 

U: Locking screw 
Y; Sterile shield 


voi,. XX. XO. 2, APRIL ISJS 




28 


RAGNAR MAGNUSSON 



Fig. 5-A 
Case 5 


the common name of “sciatica” are to be 
taken into consideration as regards the differen- 
tial diagnosis. In those cases in which symp- 
toms similar to coxitis have been added, there 
has as a rule been time for so great changes 
to develop in the ischium that they are dis- 
cernible in the roentgenogram, and for this 
reason there need be no hesitation as to the 
g g diagnosis. The same point of view can be 

. applied to those cases in which an abscess or a 

fistula has appeared. A few patients with 
well-developed abscesses in the gluteal region were treated under the 
diagnosis of “dermoid cyst” for quite a long time before their admittance 
to the hospital. In those cases where there are roentgenographic 
changes in the ischium but no sequestra, it may often be difficult to de- 
termine whether it is a question of an inflammatory process or of a tumor. 
In order to exclude lues, the Wassermann test should be made. 

Of the five cases of osteitis of unspecific or uncertain origin, in two 
(Cases 9 and 13) the disease made its first appearance in the form of a high 


'I'TTr- TOrinVAI. OP BOXK AXD JOINT SURGERY 


FIXATION OF FEMORAL-NECK FRACTURES 


453 



Fig. 6 

Incision made and pointer instrument “set” to “spot” insertion point on cortex of 
trochanter. 


in the “set” of the pointer. Figure 6 shows the pointer marking the 
position of the central axis on the cortex of the trochanter. 

The entire operation of this device is much more simple and direct 
than such a detailed explanation might imply. Much thought has been 
given toward such simplification of the device as to make it practicable 
for the use of any surgeon familiar wdth major bone surgery. 

REFERENCES 

1. Gabnslen, F. J.: Subcutaneous Spike Fixation of Fre.sh Fractures of the Neck of 
the Femur. J. Bone and Joint Surg., XVII, 739, Julj' 1935. 

2. Leadbetter, G. W. : A Treatment for Fracture of the Neck of the Femur. J. 
Bone and Joint Surg., XV, 931, Oct. 1933. 

Closed Reduction of Fractures of the Neck of the Femur. 
J. Bone and Joint Surg., XX, lOS, Jan. 1938. 


VOI,. XX. NO. 2. APniL 193S 





452 


E. W. CLEARY 



Fig. 4 

Horizontal roentgenogram. This view, due to the flexed position of the thigh, 
gives the so-called “lateral” presentation of the femoral head and neck. Line 
shadows of the localizing plotting field correspond to lines ruled on the horizontal 
plate (Fig. 3,Z/). 


the head of the instrument is lowered out of the way of the drill, and tlie 
surgeon uses the pointer pencil as a guide. If the drill is kept parallel to 

the pencil, it will pen- 
etrate to the femoral 
head along the central 
axis of the neck. Any 
advisable deviation 
from this course of the 
drill is easily deter- 
mined by studying the 

two roentgenograms 

and is easily duplicated 

Fig. 5 

Vertical roentgenogram. 
This view gives the coin- 
monlj^ called “anteropos- 
terior” presentation of the 
femoral head and neck. 
Post R of the pointer m- 
.strument (Fig. 3,il/) mus ■ 
be adjusted by means ol 
its corresponding graclua- 

tion mark to bring 
.strument head to tli^ 
height of the central ax'-'^ “I 
the liead and neck as indi- 
cated by their position on 

the line shadows of the 

localizing plotting field. 



Fig. 


the jour-v.m. of no.vK AND JOINT soncimv 




CABPOMETACAEPAL DISLOCATIONS 


455 


Roentgenographic examination revealed a posterior dislocation of the second, third, 
fourth, and fifth metacarpals on the carpals. No fractures were observed. (See Fig- 
ures 1-A and 1-B.) 

The patient refused a general anaesthetic. Local infiltration into the dislocated 
joints with 2-per-cent, procaine produced excellent anaesthesia. Reduction was accom- 
plished bj" traction and b 3 ’^ levering the metacarpals, first with slight flexion to unlock 
the bases, then pressme over the bases when sufficient e.xtension was obtained. The 
dislocations of the fourth and fifth metacarpals were reduced first, after which the second 
and third metacarpals slipped easilj' into place. There was no tendencj' toward redis- 
location. A split plaster cast was applied. (See Figures 2-A and 2-B.) 

Later, skin traction was applied to the fingers and a sponge was placed over the 
dorsum of the metacarpals, as it was feared there might be posterior slipping. All sup- 
port was removed after twentj'-two daj’s. Wrist and finger function was painless and 
normal. No further trouble has been reported. 

HEVIEtV OF LITERATURE 

There is relatii’ely little in the literature regarding thi.s injury. 
Stimson, in 1905, stated definitely that onlj’^ four cases of dislocation of 
the four ulnar metacarpals had been reported. Two of these were volar 
dislocations and two were dorsal. Most of the cases had been diagnosed 
post mortem. There was no information as to the usefulness of the hands. 



VOL. XX. xo. 2 . Arnii, isss 




CARPOMETACARPAL DISLOCATIONS 

Report op a Case 

BY HOWARD B. SHORBE, M.S., M.D., OKLAHOMA CITY, OKLAHOMA 
Instructor in Orthopaedic Surgery, University of OJdahoyna School of Medicine 

From the Slate University Hospital,* Oklahoma City 

This rare injury is of twofold interest: First, there occurs an injury 
which seemingly is impossilDle from an anatomical standpoint; second, 
very good function is usually obtained with or without reduction. 

CASE REPORT 

J. P., negro, male, aged thirty-five, came to the Emergency Room of the State Uni- 
versity Hospital on March 11, 1936, complaining of an injured right hand. The patient 
was intoxicated and had fallen down a stairway. He had no idea of how the hand was 
injured during the fall. 

Examination was negative except for the injured hand, which was severely swollen. 
There were no marks or bruises. The hand was thickened anteroposteriorly and short- 
ened. The proximal ends of the metacarpals could be palpated as a hard, transverse 
ridge across the dorsum of the wrist. Finger, thumb, and wrist motions were unim- 
paired except for a moderate amount of pain. 



454 


Fig. 1-A 

Carpometacarpal dislocation before 
* Service of Earl D. McBride, M.D. 


Fig. 1-B 
reduction. 


THE JOURXAL OF DONE AND JOINT SLRf>I.R^ 


CARPOMETACARPAL DISLOCATIONS 


457 


factors enter, — namely, the state of muscle contraction at the precise mo- 
ment of the injury; weakness, either occupational, acquired, or congenital; 
and exact conformation of the bones at these joints. With the entire 
carpus fixed, sudden flexion or extension of the metacarpals could result in 
a dislocation. The dislocation may be either anterior or posterior depend- 
ing upon the direction of the force. 

SUMMARY AND CONCLUSION 

Posterior dislocation of the carpometacarpal joints is a very rare 
injury. Due to the normal relative immobility of these joints and the 
fact that the tendons are not firmly bound in this region, unreduced dis- 
locations do not produce serious disabilities. Better results, cosmeticallj’’ 
and functionally, may be obtained by reduction, which is easily accom- 
plished in an early case under local or general anaesthesia. Reduction of 
old cases should receive serious consideration before attempts are made, 
since the onlj’’ improvement would be in the appearance of the hand, and 
it might be made a much less usable member. 

REFERENCES 

Bohi-er, Lorenz: Treatment of Fractures. Ed. 4, p. 254. Baltimore, William Wood 
& Co., 1935. 

Burk: Quoted by Hammann. 

Bdrmeister, R.: Ein Fall von Luxatio carpo-metacarpea. Zentralbl. f. Cliir., LVIII, 
462, 1931. 

Hammann: Uber die Luxatio carpo-metacarpea. Deutsche Ztschr. f. Chir., CCXXIII, 
287, 1930. 

Kev, J. a., and Conwell, H. E.: The Management of Fractures, Dislocations, and 
Sprains. Ed. 1, p. 724. St. Louis, The C. V. Mosby Co., 1934. 

ScHNEK : Quoted by Bohler. 

Stimson, L. a. ; a Practical Treatise on Fractures and Dislocations. Ed. 4, p. 693. Phil- 
adelphia, Lea Bros. & Co., 1905. 


VOL. XX. NO. c. 


ArUIL I93S 



456 


H. B. SHORBE 


Hammaun described a case of dorsal dislocation of the fifth carpo- 
metacarpal joint. He stated that the injury was very rare, Init he did not 
review other cases. His discussion was primarily concerned with the 
mechanism of production of the injury. 

Burnieister reported a case of dorsal dislocation of the second to fifth 
metacarpals. His patient received a strong blow on the dorsum of the 
hand in a car accident. He suffered little pain and refused reduction, due 
to lack of discomfort or dysfunction. He was seen two yeai’s later and 
functionally had a useful, but deformed hand. 

Key and Conwell discussed biiefl}'' tins injuiy and showed an excel- 
lent roentgenogram of the dislocation. In their opinion a backward dis- 
location is the most common of the dislocations. Functional results were 
not discussed. 

Schnek reported only two posterior caipometacarpal dislocations in 
437 cases of carpal injuries. 

ANATOMICAL CONSIDERATION 

The carpometacarpal joints, with the exception of the first, are of 
the arthrodial-diarthrosis type. The second to fifth metacarpal bases 
articulate with the distal row of bones of the carpus by a series of elevations 
and depressions which fit together rather snugly. The joints are bound 
closely by a capsule, weakest on its radial side and composed of short 
fibrous slips extending longitudinally on the dorsal and volar surfaces. 
Two interosseus ligaments are usually present, reaching from the bases of 
the third and fourth metacarpals to the adjacent margins of the hamate 
and the capitate. The common capsule encloses the entire series of 
joints, both between the bases of the metacarpals and between the carpo- 
metacarpal joints. 

METHOD OF PRODUCTION OF DORSAL CARPOMETACARPAL DISLOCATIONS 

Burk attempted to produce this di.slocation on cadavera. Usually 
he obtained fractures. It was neces.sary for him to cut the anterior and 
posterior ligaments to obtain a dislocation. The author has repeated 
Burk’s experiments with similar results. Attempts on fresh specimens 
with the carpus fixed were unsuccessful unless the anterior and po.sterior 
ligaments were divided. The dislocation could then be effected by un- 
locking the bones with flexion and pressure posteriorly on the bases of 
the metacarpals. 

No one type of injury produces this di.slocation. Direct blows may 
result in a posterior dislocation, as Burk has described. Bullets or auto- 
mobile accidents have been known to cause it. There is almost invari- 
ably soft-tissue damage with a direct injury. 

Indirect injuries unquestionably have been responsible for many of 
these dislocations, but the exact mechanism is vague. It is interesting to 
speculate on mechanical forces applied to the wrist, but any conceivable 
type of blow, twist, or bend might result in one of several injuries. Other 

THE JOHR.VAL OF HO.VE A.VD JOI.N'T .SFRf.I.fll 



COMPOUND DISLOCATION OF THE TALUS 


459 


CASE HEPORT 

Miss H. C., aged forty-two years, fell down a flight of stairs in her home and landed 
with one foot turned inward. Her family physician saw her within a few minutes, ap- 
plied tincture of iodine and a sterile dressing to the wound, and sent her to the hospital. 
She had a compound dislocation of the tibio-astragalar joint, the astragalus being rotated 
through 90 degrees, so that its superior aspect presented in an open wound on the lateral 
aspect of the ankle. The malleoli were intact and the only fracture shown in the roent- 
genogram was one of the base of the fifth metatarsal at the point of insertion of the 
peroneus longus tendon. There was a narrow bridge of skin tightly stretched between 
two parallel wounds. 

Operation was performed ten hours after the injury. First the surrounding skin and 
then the wound itself were painstakingly cleansed with abundant quantities of soap solu- 
tion and water. All contused soft tissues were excised. The dislocation was then re- 
duced and the ruptured ligaments were sutured. Very little tissue was available for the 
closure, and the joint cavity could only be sealed by using a flap of skin raised from the 
outer aspect of the leg and slid donmward over the ankle. The original wound was thus 
closed without drainage, and the site of the sliding graft was later covered with pinch 
grafts. Healing took place without infection. 

Partial weight-bearing with crutches was permitted four weeks after the accident. 
There was recovery of full range of motion at the ankle and in the foot, and, during the 
four years which have elapsed since the injury, the patient has been walking without 
pain and has had no sprains of the ankle. 



Fig. 1 

Drawing showing position of dislocated foot and sprain-fracture of the base of 
the fifth metatarsal. The displacement of the peroneus longus tendon outside 
the fibular malleolus is scliematic. 

The treatment of such a case by' debridement and .suture without 
drainage makes for a good recovery provided of eour.-^c tliat infection doc.s 
Rot supervene. Primary' closure was pos-dble in tliis case bccau.-^e of tlie 

' OL. XX, xo. 2. APRIL IMS 



COMPOUND DISLOCATION OF THE TALUS WITHOUT 
MALLEOLAR FRACTURE 

BY JOHN PAUL NORTH, M.D., PHILADELPHIA, PENNSYLVANIA 

It is commonly supposed that the talus cannot be dislodged from the 
ankle joint by injury unless one of the malleoli or a lip of the tibia is 
fractured. In the main, this is true and certainly most dislocations at the 
ankle have associated fractures of the long bones. Lateral dislocation 
accompanying fractures of the Pott type is familiar to all. Posterior dis- 
location, which occurs when the posterior liio of the tibia is broken, is also 
common. Less frequently a fracture of the anterior lip of the tibia may 
permit anterior luxation of the foot, or upward displacement of the talus 
may occur if the inferior tibiofibular ligaments are torn, with resultant 
widening of the mortise. The case reported herewith is an example of 
internal dislocation of the foot without associated fracture, and there are 
on record sufficient cases of similar character to warrant the recognition of 
the possibility of its occurrence. Prior to the x-ray era such cases were 
described, but, lacking roentgenographic confirmation, the diagnosis is 
open to question. In a review of 108 cases collected by Wendel, at least 
one dislocation appears to have been unaccompanied by fracture. Stim- 
son quotes Malgaigne to the effect that eight such cases were recorded 
prior to 1900. 

The earliest authenticated case of uncomplicated dislocation seems to 
be that of Sievers. In this case, the tibia and fibula were intact, although 
there was a chip fracture of the posterior lip of the superior articulating 
surface of the talus. Subsequently, isolated cases have been recorded by 
Pergire, Gillen, Green, Pedlow, Hirschfield, Dehne, Pegreffi, Aboulker 
and Herbert, Conwell and Alldredge, and Sloane and Coutts. In each 
instance the foot Avas rotated invmrd, so that the superior surface of the 
talus presented beloiv the fibular malleolus. In addition, Scharsich 
reported tivo cases of simple dislocation, thus making thirteen in all. 
The usual mechanism described in the production of these injuries is a fall 
or other accident of such nature that the iveight of the body is thrust 
suddenly upon the outer aspect of the inverted foot. Six of the ten dislo- 
cations were compound. In one instance the naAucular and in another the 
talus was completely extruded. These tarsal bones were replaced and, 
although the result is not recorded in the case of extrusion of the talus, the 
patient with extrusion of the navicular ivas able to vmlk normally in two 
months. Of the total number of cases, good functional results iverc re- 
ported in five cases, while in the remainder the results ivere not stated. 
One of Scharsich’s patients had a fracture of the head of the fifth meta- 
tarsal similar to that in the folloiving case. 

ICC THE JOURNAL OF BONE ANO JOI.VT SUIiOI.R'i 



TUBERCULOUS OSTEITIS OP THE ISCHIUM 


29 




temperature (Case |j pL . ~ ' 

13 in conncctioiMvith . ' 

an angina). This ' 

fact, together with 

the results of otlier 

e.xaminations (the . 

tuberculin tests ac- .. 

three milligrams of 

old tuberculin), indi- ' ■ .-■* 

cates that these cases ' 

probfibly are to be 

a high temperature. ,';1 ■■ 

In the other three ' , ■ 

cases of osteitis of - , ■ . ■ , . 

uncertain origin 

(Cases 10, 11, and \ • • , 

12), the symptoms i-- 

commenced gradu- ^ 

,, j , , ,1 Case 7. Before operation, 

ally and the whole 

disease had a protracted course, as in 

the cases of certain tuberculous osteitis. \ \\ \N. y? 

In two of these latter cases (Cases 10 I I l) \ \ 

and 12), however, the origin of the / \ 

process was uncertain. Case 10 was \ tTU I 

that of a man who, at the age of twenty- ^ 

three years, started to have pain in the ^ ] 

right leg. A few years later, an abscess J 

appeared, which was incised, and a ^ 

sequestrum was extracted. A roent- 
genogram showed destruction of the 

, , , . r , 1 • 1 i i v_ Case 7. Before operation, 

upper lateral parts of the right tuber 

ischii, as well as a slight atrophy of the whole right half of the pelvis. 
The destruction had a blunt and blurred outline toward the tuber ischii. 
As only the tuberculin test according to Pirquet had been made, which was 
negative, and as continued tuberculin tests according to Mantoux and 
other examinations (the Wassermann reaction and pathological-anatomi- 
cal examination) had not been carried out, it was not possible to make a 
definite diagnosis. The author, however, is of the opinion that the most 
probable diagnosis is that of tuberculous osteitis. Case 12 was also that 


Fig. 6-A 

Case 7. Before operation. 


Fig. 6-B 

Case 7. Before operation. 


VOL. XX, xo. 1 . jAXUAna' mss 



460 


J. P. NORTH 


conditions under which the accident occurred, the prompt and efficient first- 
aid treatment, and the early stage at which operation was done. Many 
compound dislocations must of necessity be treated by other methods, 
because of actual or threatened contamination, 

REFERENCES 

•5Vboulker, P., et Herbert, J. J.: Luxation tibiotarsienne. Ann. d’Anat. Pathol., XII, 
217, 1935. 

CoNWELL, H. E., AND Alldredge, R. H.: Complete Compound Dislocation (Internal 
Lateral) of the Ankle Joint without Fracture, with Primary Healing. J. Am. Med. 
Assn., CVIII, 2035, 1937. 

Dehne, Ernst: Ein Fall von unvollstiindiger Luxation des Talus als Folge wiederholter 
Verletzungen im oberen Sprunggelenk. Zentralbl. f. Chir., LX, 688, 1933. 

Gillen, W. A.; Compound Dislocation at the Ankle Joint. Long Island Med. J., XI, 
123, 1917. 

Green, N. W. : Discussion of paper by Milliken. Ann. Surg., LXIX, 651, 1919. 
Hirschfield, I. : Isolierte unkomplizierte Talusluxation. Zentralbl. f. Chir., LIX, 2227, 
1932. 

Milliken, S. M. ; Complete Dislocation of Ankle without Fractui’e of Leg Bone. Ann. 
Surg., LXIX, 650, 1919. 

Pedlow, E. B. ; Compound Dislocation of Tibia, Fibula and Talus. Ohio State Med. J., 
XXV, 549, 1929. 

Pegreffi, Enrico: Di un caso di lussazione talocrurale senza frattura. Riforma Med., 
L, 963, 1934. 

P^raire: Luxatio tibio-astragalienne avec issue a I’exterieur du perone non fracture H 
travers une boutonniere cutanee. Presentation de malade. Paris Chir., V, 959, 
1913. 

ScHARSiCH, K. : Isolierte unkomplizierte Talusluxation. Beitr. z. klin. Chir., CLI, 566, 
1931. 

SiEVERS, Roderich: Ein Fall von isolierter Talusluxation. Fortschr. a. d. Geb. d. 
Rontgenstrahlen, XIIL 31, 1908. 

Sloane, David, and Coutts, M. B.: Traumatic Dislocation of the Ankle without Frac- 
ture. A Case Report. J. Bone and Joint Surg., XIX, 1110, Oct. 1937. 

Stimson, L. a.: A Practical Treatise on Fractures and Dislocations. Ed. 8. Philadel- 
phia, Lea & Febiger, 1917. 

Wendel, 0.: Die traumatischen Luxationen des Fusses im Talocruralgelenk. Beitr. 
z. klin. Chir., XXI, 123, 1898. 


the journal of done and JOI.N'T .sURf'LH 



HIP FRACTURES 


Valgus Position — ^Accidental or Engineered 

BY FREDERIC JAY' COTTON, M.D., AND GORDON MACKAY' MORRISON, M.D. 

BOSTON, MASSACHUSETTS 

It is a well-recognized fact that, wliatever treatment is resorted to, 
vastly better results are obtained in intracapsular fractures of the neck of 
the femur if the displacement happens to be into the “valgus” position. 
(See Figure 1.) 

What is new is that we ha^'e lately learned how to produce this valgus 
position at will, and consistently. 

There is no question that with a valgus position one gets a more 
favorable line of muscle pull, less damaging strain from weight-bearing in 
the sense of cross strain, and the tendency is toward lengthening rather 
than shortening of the leg. We knew this long ago, and many of us have 
tried for a consistent technique by which we could shove the fragments 
into the valgus position. We failed uniformly. 

And some of us did vast and futile experimentation on the cadaver 
and on the living, to contrive a 
“valgus” reduction, but with no con- 
sistent results! 

Only lately, when we finally ob- 
tained “lateral” roentgenograms of 
adequate quality, did we realize the 
prewously overlooked factor of for- 
ward rotation of the proximal end of 
the distal (neck) fragment. 

Only with this vision was it po.s- 
sible to work out accurate reduction. 

Prior to 1933, Leadbetter and 
one of the writers devised manipula- 
tion independentlj’’, curiously similar in detail, for accurate reduction. 

The writer then exprcs.sed a liope that such accurate reduction might 
in itself solve the problem of absorption of the neck. 

But it failed to do so. Absorption of the -proximal fragment (inde- 
pendent, it seems, of the arterial nutrition of the head) goes on in 1938 
ju.st as in 1933. 

We have moved ahead slowly and can say for the first time that a hij) 
fracture accurately reduced by met hods quoted can be furt her retlueed into a 
valgus position with a vast advantage, and this can be done with precision. 

The fact is that a hi]5 fracture, once accurately reduced, can l)e con- 
verted into a valgus po.dtion rather exactly with very significant benefit a< 
measured by end results. 

The artificial iniiiaction of hiiJ fractures —even of hiji fractures not 



Left: The usual “varus” position of 
so-called “impaction”. 

Right: Tlie “ valpus” position. Note 
the difference measured in cross- 
breaking .strain. 



462 


F. J. COTTON AND G. M. MOKRISON 


^ . always well reduced— dates back 

^ 10 ^ years. The senior writer, fol- 

/ lowed by Smith-Petersen and many 

I I V/ / others, has done many impactions, 

\ I / \ / / results which yielded at least 

\ 6 \ I I personal satisfaction and probably 

If \ I I great benefit. 

^ However, these have been im- 

pactions in the line of the neck. 

tiif' “"“">‘“1 ■■'<>«»- Now we have learned, but only 

Right: Impaction into "valgus”. Di- ' lately, that we can imiDact a neutral 

rection of impaction in and downward. vPc\uoi\m', infn fha nncHinn nf ‘‘mlniKi” 
Note the weight-bearing line and the reGucuon MUO t/ie postitott oj valgus 

difference in "cross-breafing” strain. to a position that we know to be far 

more favorable to recovery and 
union, and, like so many things of importance, it is ridiculously simple. 

The procedure is to reduce the hip accurately by the method notv in 
use, — namely, traction in the line of the femur, hip and knee being moder- 
ately flexed; sharp adduction; knee crossed over the thigh of the sound 
side; sharp inward rotation of the broken limb, followed by bringing the' 
leg down into slight abduction (20 degrees more or less) without letting 
up on the inward rotation. (See Figure 2.) The result is checked both by 
anteroposterior and lateral roentgenograms. It may be necessary to 
repeat this manoeuver. 

This method of reduction requires some force, and there is little 


chance of overreducing. In only one 
out of many cases have we been 
obliged to repeat the procedure because 
we had overreduced the displacement. 
The usual fault is in not using enough 
force. 



Figs. 3, -I,’ and 5: Typical cases of 
accidental v'valgvis displacement with 
subsequentdiony union. 



Fig. 5 


THE JOURN-AI, OF BONE AXD JOIN'T SUUGr.E' 



HIP FRACTURES 


463 



Fig. 6 


Fig. 7 



Fig. S 

Figs. 6, 7, and S: Other typical cases of accidental valgus displacement with 
subsequent bon 3 ' union. 


When satisfactory position is attained, comes the time for converting 
the neutral (normal) position into ralgiis by impaction. 

The leg is abducted 20 or 30 degrees from the mid-line of the body. 
In obese patients one cannot abduct much and still reach the trochanter 
to impact. We use a heavy wooden mallet to impact with, the limb being 
protected by a single layer of heavj* felt. A tightly stufTed cylindrical 
sandbag of four-inch thickness can be used and with this no felt is needed 
for protection. We have done many impactions in this way. but we feel 
that the hammer gives more exact control and. with this newer imjiaction. 
exactness is essential. 

With the hammer, the trochanter is struck and driven home. The 
blow i.s a slow swing of the heavy mallet. 

VOL. XX. .XO. 2. 


.\rnn, i"’-; 






464 


F. J. COTTON AND G. M. MORRISON 


The direction of tlie blow is not in the line of the neck, as with the old 
impaction procedure, but across it at an angle of roughly 45 degrees with 
the mid-line of the body. 

Since the limb is already abducted, this gives a total angle of from 70 
to 75 degrees or, perhaps better stated, an angle of from 105 to 110 degrees 
with the shaft. 

The force, then, is applied in a line to push the neck fragment aeross 
under the head at the same time that the neck is impacted into the head. 
This can be done quite exactly with a little practice. We have never . 
failed as yet to get the desired position. 

A word of caution is neces.sary : It is Amry important that the bloAA’’ be 
struck parallel to the table. There is a possibility of shoAdng the neck 

fragment to front or back. 

FolloAving reduction and impac- 
tion, Ave have nailed the fragments 
Avith Krupp nails from three to three 
and one-quarter inches long according 
to the indiAudual case. The incision 
is small ; drilling is done under fluoro- 
scopic control; and the nails are in- 
serted in the drill holes and tapped 
home, using a nail set. 

Then, gently, the final impaction 
is done Avith the impactor devised 
by Smith-Petersen, Avhich straddles 
the nail and rests on bone. 

Suturing and dressing follow. 

In only one case (when patient 
tracture of hip with loose fragments. was coiwalescent) haA^e AA^e used a 

Thomas splint and in no case have Ave employed a plaster spica. 



Fig. 9-A 



Fig. 9-B 

After reduction. Fragments in valgus. 


Fig. 9-C 

Fragments nailed. 

THK JouKN’Ai- or noN'i: avd joi.vt si 


HIP FRACTURES 


465 



Fig. 10-A 


Fig. 10-B 


First case deliberately treated by the After nailing. The patient at prcs- 

technique described, before reduction. ent has serviceable bony union. 


It may be well to add a brief account of the reasoning that led to the 
devising of this new method. 

In recent years we have had occasion to treat not a few broken hips. 
Those that have interested us particularly are the.se “valgus” hip.-^, per- 
haps eight in all. 

These are cases, often in relatively jmung people, of intracapsular 



Fig. 11-.\ Fig. ll-H 


tracture of the hip with loose frag- 
ments. 


.\ftor reduction, impaction, and nail- 
ing. Patient at present convale.-eent. 
.\pparently a very favondde ca.'a>. 


'■"l- .\N. .NO. j. . 


.^I’UII. 103S 




466 


F. J. COTTON AND G. M. MORRISON 


fracture with little upward displacement and with little or no roiary dis- 
placement. The displacement, such as it is, is of the dzs/al fragment inivard. 

The significant factor in the history— from those with any useful 
memory of the accident— is uniformly that of a crash sideivatjs onto the 
trochanter. 

This is an entirely different story from that of the elderly patient 
whose leg gives way in mid-air or who sits down half sideways in a sitting 
“squash” fall. 

This seems most significant if we accept the stories. We do. In 
these patients the distal part of the hip is driven inward: 

without rotation 
without great displacement 
without great damage to capsule 
without damage to ligamentum teres 
without damage to pericapsular vessels. 

And, therefore, they do well from the start, and the course of repair is 
continued without the handicap of any cross strain from muscle pull or 
weight-bearing. 

It is scarcely to be hoped that in cases of different initial mechanism, 
of greater soft-part damage, that a reproduction of the imlgus position can 
bring the worst cases quite into the better class, but we believe it to be 
a very important factor. 

No claim is made that such reduction with impaction has any effect 
in avoiding or reducing the ‘^death of the head” * or the aseptic necrosis 
and absorption of the near end of the distal fragment, due, one supposes, 
to damage of the blood supply, mainly arterial. Over these calamities 
we have no control as yet. 

But, if the neck (spiked or unspiked) is going to absorb, then the val- 



Fig. 12-A 

Fracture of the hip with loose fragments. 

* Real, but a bit overplaj'cd perhaps— not usual or common. 

THE JOUR.VAL OF BOXE AXO JOTXT •SCnOER'i 



HIP FRACTURES 


467 



Fig. 12-D Fig. 12-E 

After drilling under fluoroscopc. .\fter nailing. 


gus position is the posture in wliieh the Iione may liest resist tliis mis- 
fortune. 

A veiy considerable number of such ca.^es (the neck alisorlied) go on 
(protected) within a j’^ear to bonj’’ or, at worst, scrrircabic close fibrotis 
union, whatever tlie exact detail of treatment. But the.'^e are u.«ually 
“valgus” cases. 

We believe thi.^; matter of coiilroUcd determination of jio.^ition to lie 
verj’ important. 

It is too soon to talk of re.^^ults. Probably they will not be con- 
sistently good, but we believe they will be better. 


von. XX. xo. 2. .\rniL ipss 




468 


F, J. COTTON AND G. M. MORRISON 


After all, this whole problem of iiitracapsiilar hip fracture is only for 
the optimist. 

Some of those who have worked on it for thirty 3 '-ears have the bitter 
taste of failure and a bit of skepticism about reiiorted 100-per-cent, results. 

But, results can he bettered, are being bettered, and this matter of con- 
trolled reduction into valgus may well prove an important factor. 

REFERENCES 

Cotton, F. J.: Artificial Impaction in Hip Fracture. Am. J. Orthop. Surg., VIII, 680, 
May 1911. 

Intracapsular Hip Fracture. J. Bone and Joint Surg., XVI, 105, Jan. 

1934. 

Leadbetter, G. W. : a Treatment for Fracture of the Neck of the Femur. J. Bone and 
Joint Surg., XV, 931, Oct. 1933. 


and joint scicniuiY 


THE JOL’RN.VL or no.vE 



A BONE PLATE WHICH WILL NOT BREAK OR BEND 

BY GEORGE W. HAWLEY, M.D., WESTPORT, CONNECTICUT, AND 
RALPH D. PADULA, M.D., NORWALK, CONNECTICUT 

The occasional accident of bent or broken plates, in the hands of ex- 
perts in the large medical centers, caused the Fracture Committee of the 
American College of Surgeons to appoint, a few years ago, a special com- 
mittee to find ways and means to reduce this hazard. For the past ten 
years the senior YTiter has been working on a bone plate which will not 
bend or break and yet is technically easy of application and removal, 
should removal at any time be desired. At the same time, the effort has 
also been made to obtain unusually strong fixation of the plate to the bone. 

The plate shown in Figures 1, 2, and 3 appears to meet these require- 
ments. It has been tested for tensile strength on human dried bones and 
cadavera. It has been used in two cases of fracture of the shaft of the 
humerus, in two cases of fracture of the tibia, and in one case of fracture of 
the femur. As there is no essential difference between this plate and the 
Sherman plate from a clinical point of view, the case reports are omitted. 
In each case early callus has been observed in the roentgenograms, and no 
loosening of the screws has been noted. We have no idea what future e.x- 
perience may prove, — whether the screws eventuallj’^ will become loose, 
and, if so, how early. As yet we have not removed a plate. 

There is little technical difference in the application of this plate and 
the Sherman plate. The junior writer, who has carried out the experi- 
mental operative work on cadavera and dogs, has found a method of ap- 
plication which makes the operation somewhat easier and quicker than 
applying a Sherman plate. 

The plate is an angle iron made of stainless steel, and is fairl}’ thin, 
light, and compact. There is one size of plate for the femur and the tibia 
(weight-bearing bones), one for the tibia and the humerus, one for the 
humerus, and one for the radius and the ulna. Long screws are used so 
that they pass completely through the bone and cxiend about one-fourth 
of an inch. This is to ensure good threading and to hold in the distal 
cortex. The plate is applied from the side of the bone, so that the screw 
ends are visible. The ends of the screws are cut off flush witli the Iione by 
means of a jeweler’s wire saw. With tliis small instrument, a notcli is cut 
on the side of the screw which breaks off by bending. The burred screw end 
makes it more difficult for the screw to pull out, but does not hinder removal. 

Two drill points are used. One is for the cortex distal to the plate 
and has been carefully selected, so that it is neither too small nor too large. 
If the drill point is too small, it is difficult to insert the screw without 
breaking its head. If the point is too large, the screw does not get a 
secure hold on the bone. Screws act to thread the hard bone and must 
obtain a firm hold. The other and larger drill is for the cortex proximal to 
the plate. This drill makes a hole .“jlightly larger than the screw. 


VOl.. XX. NO. 


Ai'iiii. 


-too 



470 


G. W. HAWLEY AND R. D. PADULA 



Fig. 1 

Showing sizes of plates : 

1 : Plate for femur and tibia, four inches long, with flanges three-eighths of an inch wide 
and one-sixteenth of an inch thick. 

Plate for tibia and humerus. 

3: Plate for humerus. 

4-’ Plate for radius and ulna, two inches long, one-quarter of an inch wide, and three- 
sixty-fourths of an inch thick. 

5, 6, and 7: Drills used: gage 34, 35, and 28. 

lA: Screws for large plates: one and one-quarter inches, one and one-half inches, and 
one and three-quarter inches by one-eighth of an inch in diameter. 

2 A: Screws for small plate: one-haif an inch and five-eigliths of an inch by five-si.xty- 
fourths of an inch. 

A : Circular saw, one-sixteenth of an inch wide. 

B5: One way of cutting slot for plate, given up for method described in text. 

C: Jeweler’s saw for cutting notch in ends of screws, so that the ends break off easily. 

Al: Cross-section of plate and bone. 

A2: Lateral view of plate attached to bone. 

3 A and 4A: Diagrammatic views of plate, showing some screws cut off. 

Our experiments show that six screws are advisable for the weight- 
bearing bones (the tibia and the femur). For the non-weight-bearing 
bones, we believe that four screws — ^two in each fragment — are sufficient. 

The junior writer has arrived at the following technique after experi- 
menting on cadavera and dogs and after operations on patients: 

An incision is made to expose the bone on its outer surface. Ex- 
posure is free and adequate. In fractures of the tibia and the femur, the 
leg is put in traction on a fracture table to stabilize the limb and to reduce 
partly overriding and deformity. The bone ends are fullj'’ freed from the 
soft parts. No attempt is made to approximate the ends at this point, 
except to align and to mark each fragment with a sharp instrument for the 
longitudinal saw cut. One bone end is then lifted out of the wound, aiul a 
slot is cut with a motor saw. The blade of the saw is of the same thick- 


THE JOUnXAL OF BON'E A.VD JOI.VT .SCIlOKnX 




30 


RAGNAR MAGNUSSON 


of a man who, after 
having received a 
trauma to the left 
hip at the age of 
twenty-eight, had 
pain periodically over 
the loft tuber ischii. 
He had been oper- 
ated on repeatedly. 
No pathological-an- 
atomical examina- 
tion, however, had 
been performed. 
When the patient 
was examined at the 
Coast Sanatorium, 
the Pirquet reaction 
proved positive. 
The Wassermann 
and Kahn reactions 
were negative. Prob- 
ably this is also a 
case of tuberculous 
osteitis. This opin- 
ion is strengthened 
by the fact that 
the patient, as a 
child, had a definite 
tuberculous infection (exudative pleu- 
risy). Case 11 is an example of a chronic 
septic osteitis of the ischium. In most 
cases it is probably impossible to dis- 
tinguish a tuberculous osteitis of the 
ischium from a septic one by mere roent- 
genographic examination. Nevertheless, 
the septic osteitis in these cases seems to 
leave a more sclerotic bone delineation 
and sharper outlines of the destruction 
than does the tuberculous osteitis. 

Of the eight patients with certain 
tuberculous osteitis, one was treated conservatively (on account of a very 
advanced pulmonary phthisis), and the others were operated on. In three 
of the latter cases (Cases 2, 4, and 6), only sequestrectomy was carried 
out. In two of the four remaining cases (Cases 3 and 5), gouging, scrap- 
ing out, and sequestrectomy (Case 3) were performed; in the other 
two cases (Cases 7 and 8), subperiosteal resection of the tuber ischii 



Fig. 7-B 

Case 7. After operation. 



Fig. 7-A 

Case 7. After operation. 


THE JOITRVAL OK BO.VE A.VD JOINT SUnGETtY 


TYPHOID SPINE 


BY H. A. SWART, M.D., F.A.C.S., CHARLESTON, WEST VIRGINIA 

Typhoid involvement of the spine has never been common; accord- 
ing to Gall, the incidence is one case in every 1800 cases of typhoid fever. 
In recent years, due to better milk and water supplies, it has become quite 
rare. The following case is interesting in that the patient was under 
observation from the time of onset of the typhoid fever, through the period 
of active involvement of the spine, until apparent cure was effected. 


CASE REPORT 


A. P., white male, aged nineteen, unmarried, was admitted to the Charleston General 
Hospital on February 22, 1936, with the history of having suffered from chills, fever, 
delirium, and diarrhoea for two weeks. On admission his temperature was 104.4 de- 
grees, and the pulse rate was 120. Physical examination revealed the presence of herpes, 
congestion of the pharj’nx, and a markedlj' distended abdomen. The blood count 
showed 4,100,000 erythrocytes, and 10,100 leukocytes, with hemoglobin of 91 per cent. 
The Widal blood test was reported positive by bacillus typhosus in a dilution of 1 :500. 
The disease ran a stormy course with marked delirium and fever up to 105 degrees for 
two weeks. He was given intravenous fluids and blood transfusions, following which his 
temperature subsided. He was allowed to go home on March 22. 1936, after having been 
in the hospital one month. 

The patient returned to the hospital on April 23, 1936, with the complaint of low- 
back pain, accompanied by fever, which he had had for one week. His local phj’sieian 
had found pus in the urine. On the day of admission he had had a chill. Examination 
at this time revealed tenderness and muscle rigidity of the right lumlsar region. His 
temperature was 103.6 degrees. Analysis of the urine showed a definite amount of 
pus, — 2 plus on a basis of 4. Reexamination of the blood disclosed nothing significant. 
A test for undulant fever was negative. Roentgenographic examinations of the chest 
and abdomen were negative, except for the finding of scoliosis of the lumbar spine to the 
left. A retrograde pyelogram w'as made on May 4, 1936, anil nothing was shown except 
the scoliosis to the left as before. A roentgenogram on May 20, 1936, showed only 
scoliosis of the lumbar spine. A diagnosis of pyelitis was made and the patient was put 
on a ketogenic diet. His temperature fluctuated in an irregular manner, but gradually 
came down to normal at the end of three weeks. The pain gradualb’ became le.ss and at 
the end of sixty days, on June 26, he was again dismissed from the hospital. 

The patient was readmitted to the hospital on August 1, 1936, at which time he was 
first seen by the author. He complained of a severe aching in the right lumbar region. 
He also stated that the right leg was shorter than the left, and that the left leg was weak, 
forcing him to use crutches to get about. Examination revealed a total curve to the left 
in the lumbar area. There was no particular tenderne.ss of the sjiine or adjacent imi-icles. 
Motions of the spine produced pain in the right hip. There was marked weakness of 
the muscles of the left leg with al)scncc of the knee jerk on that side. The ankle jerk, 
however, was present. In the right leg all reflexes were active. There was atrojiiiy 
of the left thigh, amounting to two centimeters, but none in the calf. The spinal fluid 
was examined and found to be negative. I'rinalysis was negative and blood studies 
werc again not significant. 

A roentgenogram of the lumbar spine (Figs. l-.Aaiid I-Hi revealed a dest met ive jiroc- 
c.“s between the second and third lumbar vertebrae with mvolvenieiit of the di-c ami s'-oli- 
osis to the left as liefore. The teiiijienitune at tin- time wa- norm.il. diagiio-i- of 


vou XX. .NO. 2, , 


47.'5 


.WRII. I'.US 



472 


G. W. HAWLEY AND E. D. PADULA 


ness cas the plate. Wlhle the bone end is raised, one-half of the plate is 
inseited into the slot and the bone is drilled, — first, the distal cortex with 
the smaller drill; then, the proximal cortex with the larger drill. The 
screws are then inserted and the ends are cut off. 

The other bone end is raised out of the wound, and a saw cut is made 
in the line already marked. The fragments are then approximated, and 
the plate is slipped into the bed which has been prepared for it. The ends 
are then impacted one against the other by pressure in the long axis of the 
bone. The final screws are inserted and the ends are cut off. The wound 
is closed, and dressings and a cast are applied. 

We wish it to be understood that we do not advocate the operative 
treatment of fractures, except in certain cases in which operation seems 
justified. On the contrary, we believe that plating operations should be 
left to those with adequate training and instrumental equipment. We 
simply offer this plate as a substitute for the Sherman plate, solely by 
reason of the fact that if, will not break or bend. 


Since the above was written, we have been using plates made of 
vitallium, an alloy w^hich does not contain iron and which resists corrosion. 

The scientific and painstaking experiments carried out by Dr. C. S. 
Venable on the electrolysis induced by different metals buried in living 
tissue show that vitallium is devoid of electrolytic action, and so-called 
“eighteen and eight” stainless steel (18 per cent, chromium and 8 per 
cent, nickel) has very little. Both are highly resistant to corrosion. At 
the present time w'e are inclined to believe that there is little choice be- 
tween the two, but in this we may be mistaken. 

The plate which we have described was informally presented at the 
Annual Meeting of the Fracture Committee of the American College of 
Surgeons in New York, on February 18, 1938. The question of cutting 
the slot wms raised. In our experimental operations we expected to en- 
counter some difficulty, but in practice the cutting of the slot and the 
fitting of the plate proved quite easy. One difficulty is, however, quite 
obvious. This is the use of penetrating screws which have to be cut off. 
Our experiments indicate that this provides the strongest anchorage of the 
plate. It may be that this is not necessary, that screws which just pene- 
trate the full diameter of the bone are sufficient. It is not difficult to 
select such screws by measuring the diameter of the bone at operation. 
Such screAvs are advised when a plate is applied on the anterior suiface 
of a bone and not from the side, so that the screws are visible. A plate 
may be applied with scrcAVs which only penetrate the cortex next to t le 
plate, but the hold of the plate depends on the screAVS, and our tests show 

that, under strain, such scrcAA-s Avill pull loose. i i r u 

Weakness in the screAV, near the head, is the only structina c e ec 
Avhich Ave haA^e encountered. Not often, but occasionally, the heac o a 
screAV has broken off at operation. With more careful introduction tins 

Avould probablj" not occur. 

THE JOUHN'AI. OF HON'E AND JOINT SMtOf.n 



TYPHOID SPINE 


475 


Mercer and Jones and Lovett state that such a condition is osteo- 
myelitic in character, but in the present case the process appeared to be 
an osteitis rather than an osteomyelitis, as there was at no time any 
evidence of abscess formation. 

This case shows that, in addition to involvement of the vertebrae 
in typhoid spine, the nerve roots may also be affected. Mercer states 
that frequently tenderness along the sciatic nerve, hyperaesthesia of the 
lumbosacral region, and sometimes anaesthesia of certain parts of the 
hip and the leg are noted. He also points out that the reflexes are usually 
increased. In this case the knee jerk on the left side was abolished at 
one time, and there were no sensory changes. 

According to Mercer, the roentgenographic changes show broadening 
of the intervertebral discs with deposits of bone on the lateral aspects of 
the affected vertebrae. Our roentgenograms, however, showed destruc- 
tion of the intervertebral discs and the adjacent borders of the vertebral 
bodies. 

Whitman states that the symptoms usually last six months, and 
that the outlook is good. In our case, we allowed the patient to go with- 
out support at the end of eight months, and he was apparently com- 
pletely well in one year. It is felt that recovery in this case was expe- 



Fig. 2-.\ Fig. 2-H 


Litoral and anteroposterior rooiitKcnopranis of tlie lumbar spine, sliowini: loss of 
tlie dise between the second and tbinl lumbar vertebrae witli evidence of healim: 
of tlie le,sion. 

voi,. XX. NO. a. . 


■M’llIL I!)3S 


474 


H. A. SWART 


typhoid spine was made, and the patient was placed on a hyperextension frame with ten 
pounds of traction by Buck’s extension on each leg. This was left on thirty days, and some 
improvement of the scoliosis was noted. A lij'^perextension cast was then applied from 
the upper chest to the knee on the right, and twelve days later the patient was allowed 
to go home \vearing the cast. 

He remained comfortable in the cast, and at the end of three months it was removed. 
At this time the patient stood tilted slightly to the right, and a roentgenogram showed 
almost entire disappearance of the disc between the second and third lumbar vertebrae. 
A Taylor brace was obtained for him, which he wore regularly for four months. Then 
he was allowed to leave it off one hour per day and this was gradually increased until 
the brace was discarded. 

On June 1, 1937, ten months after the diagnosis was made, motions of the spine were 
found to be good and painless. There was a slight curve to the left in the lumbar region, 
but his back gave him no trouble. 

On July 19, 1937, the patient came to the hospital for permission to go to work. 
The mild scoliotic curve to the left was still present, but all motions were completely 
painless. A roentgenogram at this time (Figs. 2-A and 2-B) showed loss of the disc 
between the second and third lumbar vertebrae with evidence of healing of the lesion 
and scoliosis with convexity to the left. 

On August 5, 1937, the patient was again seen. He stated that he had worked 
eight days and had then stopped because he did not like his work, not because of pain 
in his back. Examination at this time revealed what seemed to be a normal spine with 
the exception of the slight curve. The left knee jerk had reappeared, and the circum- 
ference of the thighs was the same. 



Fig. 1-A a 

Lateral and anteroposterior roentgenograms f, ^^'^^ebrae’uJB^ 
destructive process between the second and third lumbar vertenrae 

ment of the disc and left scoliosis. 

THE JOUn.VAL OF nOXE AND JOINT SORGFRV 


BILATERAL UNDESCENDED SCAPULA WITH 
OMOVERTEBRAL BONE 


BY PARKER C. CARSON, M.D., SPRINGFIELD, MASSACHUSETTS 
From the Shriners’ Hospital for Crippled Children, Springfield 

Congenital elevation of the scapula with omovertebral bones is an 
uncommon congenital anomaly. In 1908 Horwntz reviewed the literature 
and found twenty-seven cases. Shore surgically removed a unilateral 
omovertebral bone, and Jackson reported a similar case, describing the 
condition as being costal in origin and attached to the scapula by cartilage. 
Jackson’s contention that the term "congenital elevation of the scapula” 
is a misnomer appears quite sound, since, as he points out, embryologically 
the condition represents failure of the bone to descend. Bilateral occur- 
rence of the condition appears to be exceedingly rare, and the following 
case is presented for this reason. 

CASE REPORT 

A twelve-year-old girl was admitted to the Shriners’ Hospital for treatment of a bi- 
lateral deformity of the shoulders, a left club foot, and bilateral hallux valgus; all of 
these conditions had been present since birth. The past history and family history were 
not significant. 

Physical Examination 

The general examination showed a well-nourished adolescent girl in good health. 
Orthopaedic examination revealed a short, thick neck with no limitation of movements. 
(See Figure 1.) The right scapula was high with a verj' prominent acromion process 
anteriorly. The superior border was at about the level of the fifth cervical vertebra, and 
the inferior angle was at the level of the fifth rib. The scapula was slightly movable. 
It measured five and one-half inches from the superior border to the inferior angle and 
seven inches from the acromion process to the medial angle. No definite omovertebral 
bone was palpated. The right clavicle was markedly angulated anteriorly in its distal 
third. The left scapula was immobile and firmly attached at about the seventh 
cervical vertebra. A definite process was palpated from the medial angle to the spinous 
process. The superior border was somewhat lower than the right with a le.s.s prominent 
acromion process. The scapula measured five inches from the superior border to the 
inferior angle. A definite medial angle was not palpated. The inferior angle wa.s at the 
fourth rib. A definite scoliosis to the right, centering at the tenth thoracic vertebra, 
with moderate rotation was present. The lunibo.sacral articulation was rigid. The 
superior extremities were normal with the exception of limitation of abduction and cir- 
cumduction at the shoulder joints above the level of the joints. The inferior extremities 
were normal except for an equinovarus of the left foot with a marked cavus. The left 
ankle joint was rigid in cquinus at 110 degrees. Bilateral hallux valgu*; was present. 
Neurological examination was essentially normal. 

Preoperative Pocntgcnographic Examination 

An anteroposterior roentgenogram of both shoulders (Fig. '2), including the lower 
cervical .spine, showed long transverse processes of the sixth cervical vertebra with spina 
bifida of the fifth, sixth, and seventh cervical vertebrae. These proccs-es arliculatetl 

•1 < 7 


'"On. .x.x. xo. 2. Ariiii. ipjs 



476 


H. A. SWART 


dited by traction in hyperextension on a convex frame, and by the con- 
tinuation of the hyperextension by the cast and the brace. 

REFERENCES 


Gall: Quoted by Whitman. 

Jones, Sir Robert, and Lovett, R. W.: Orthopedic Surgeiy. Ed. 2. Baltimore, 
William Wood & Co., 1929. 

Mercer, Walter: Orthopaedic Surgery. Ed. 2. Baltimore, William Wood & Co., 
1936. 

Whitman, Royal: A Treatise on Orthopaedic Surgery. Ed. 8. Philadelphia, Lea & 
Febiger, 1927. 


the journal of nONL 


and joint .‘itmCLRV 



BILATERAL TJNDBSCENDED SCAPULA 479 



Fig. 2 

Preoperative roentgenogram, showing long transverse processes of tlie sixth cervi- 
cal vertebra with spina bifida of the fifth, sixth, and seventh cervical vertebrae. 
The processes articulate with the medial margins of both scapulae. 



Fig. 3 

Postoperative roentgenogram, .showing eomiilete removal of the bone wliich 
articulated witli the scapulae and a slight .scoliosis of tlie cervical spine to the left. 


voi, XX. xo. 2. Arnii. loss 




478 


P. a CARSON- 


with the medial margins of both scapulae; this was most marked on the left where the 
ai ticulation closely resembled a sacro-iliac joint. ’ 

An oblique roentgenogram of the shoulders and scapula failed to show on the right 
any articulation between the transverse process of the scapula; on the left, however thL 
as a definite articulation, slightly wider than a sacro-iliac articulation, but otherwise 

very similar to it. 

An anteroposterior 
roentgenogram of the tho- 
I'acic spine revealed scoli- 
osis of the mid-thoracic 
spine four centimeters to 
the right. 

An anteroposterior 
roentgenogram of the lum- 
bar spine and pelvis dis- 
closed sacralization of the 
transverse process of the 
fifth lumbar vertebra on 
the right. 

Anteroposterior and 
lateral roentgenograms 
showed rather marked lial- 
lu.\' valgus of both feet, pcs 
cavus of the left foot, and 
pes planus of the right foot, 
but the bones of the right 
foot appeared normal. 

Operation 

An operation for re- 
section of the anomalous 
bony process between the 
scapula and the si.vth 
cervical vertebra was done. 



Fig. 1 

Patient before operation. 


A transverse incision was made beginning at the spine of the left scapula; this was carried 
to the spinous process of the seventh cervical vertebra and over and across to the spine of 
the right scapula. The base of the spine of the scapula and the adjacent body of the bone 
were exposed by subperiosteal dissection, disclosing immediately the anomalous process; 
this was attached to the medial angle throughout its length by a cartilaginous plate whicii 
showed no evidence of joint formation. The process measured approximately two and 
one-half inches at its attachment to the scapula; it tapered down to about three-fourths 
of an inch in size and was attached to, or a part of, the transverse process of the sixtii 
cervical vertebra. The scapular end of the bone was freed by cutting tlirough the 
cartilaginous lajmr; then subperiosteal dissection was carried down to the vertebral 
origin of this process, where it was removed near the vertebra with a Gigli saw. Small 
remaining fragments were trimmed with bone cutters. When the bone was removed, the 
scapula showed relativelj’’ normal mobility. The dissection was then shifted to the right 
side where a similar px'ocedure was carried out. The anomalous process on this side, 
approximatelj’’ three inches in length, showed a pseudarthrosis with the scapula, the tip 
having a cartilaginous plate without a definite joint formation. The process on this side 
moi’e nearl3^ resembled a rib and, at its vertebral end, there was a constriction similar to 
the neck of the rib and an irregular faceted articular end. The direct attachment of this 
end to the vertebra was not e.xamined, since the direct e.xposuro would require a con.sidcr- 
able amount of dissecting which appeared to be unnecessary. The bone was remove 
subperiostealh’. The scapula on this side, however, did not show the marked increase 

THE JOURNAL OF BONE AND JOINT SUnGLRr 



TUBERCULOUS OSTEITIS OF THE ISCHIUM 


31 



Fig. 8 
Case 9 


and the adjoining parts of the superior ramus was done. In the latter 
two cases, the operation was performed under lumbar anaesthesia, with 
the patient lying in a prone position. The other operations were carried 
out under ether narcosis. Of the cases of osteitis of unspecific or un- 
certain origin, two (Cases 10 and 11) were treated conservatively; se- 
questrectomy and gouging were done in two (Cases 9 and 12) ; and sub- 
periosteal resection was carried out in the remaining one (Case 13). 

In all of the cases operated on the wound was closed immediately. 
In five of the cases of certain tuberculous osteitis, fistulae were found at 
the operation. In some of the cases, fistulae appeared shortly after the 
operation or later on in the operative cicatrix, and in a few cases it was 
necessary to perform a second operation (sequestrectom3'')- -^t their 
discharge from the hospital all of the patients except two (Cases 1 and 2) 
were healed. According to the information received from these patients, 
they have remained healed and otherwise free from symptoms. Milch 
has recently given an account of the technique used in operations on the 
ischium. At the gouging and resection in the cases described in this paper 
great stress was laid on maintaining the periosteum intact as far as po.ssi- 
ble, in order to secure the circulation from without and thus lessen the 
chances of the occurrence of new sequestra. The periosteum is cut 


VOL. XX, XO. 1. JANUARY 193S 



480 


P. C. CARSON 


mobility that was found on the left, and posterior displacement of the scapulae was 
probabl}'^ inliibited by the clavicles. 

Postoperative Roentgenographic Examination 

A postoperative roentgenogram of both shoulders and cervical spine (Fig. 3) re- 
vealed complete removal of the bone which articulated with the scapulae. The cervical 
spine showed a slight scoliosis to the left. 

End Result 

The postoperative course was uneventful. Both scapulae are freely movable. The 
left is well displaced backward with the inferior angle at the fifth rib. The position of the 
right is unchanged. Functionally, the patient can raise both arms well above the level 
of the shoulder joints, with better results on the left. 

REFERENCES 

Horwitz, a. E.; Congenital Elevation of the Scapula. Sprengel’s Deformity. Am. J. 
Orthop. Surg., VI, 260, 1908. 

Jackson, B. H. : Undescended Scapula with an Omovertebral Bone. Radiology, XIX, 
67, 1932. 

Shore, B. R. : Congenital Elevation of the Scapula. Surg. Clin. North America, XI, 
667, 1931. 


THE JOURNAL OF BONE AND JOI.VT 


SUROBRY 



PREGNANCY COMPLICATED BY OSTEOPETROSIS 


Report of a Case 

BY HARLEY E. ANDERSON, M.D., OMAHA, NEBRASKA 
From the Department of Obstetrics, Immanuel Hospital, Omaha 

Osteopetrosis, a fairly rare condition, sometimes called osteosclerosis 
fragilis or marble bones, M’as first described by Albers-Schbnberg in 1904. 
By the end of 1936 some eighty-three cases had been reported. 

As the name “marble bones” implies, the bones of the entire skeleton 
become very hard, with replacement of the spongiosa by compact tissue, 
and with extraordinary increase in the calcium content. The most com- 
mon symptoms are spontaneous fracture and anaemia; the next common 
are hydrocephalus and blindness. 

A review of the cases of osteopetrosis shows the greatest percentage 
occurring in children, some in utero; also a larger number of females than 
males. The consensus of opinion is that this disease is a hereditary, 
familial, and constitutional one; the etiology is unknown, although several 
theories have been advanced. Careful perusal of the literature revealed 
no case complicated by pregnancy. For this reason, and because of its 
interest, the following case is reported. 

CASE REPORT 

Mrs. W. C., secundigravida, primipara, aged twenty-six, was seen on August 4, 
1936, complaining of weakness, exhaustion, and an amenorrhoea of two montlis’ duration. 

The history of the 
patient disclosed a preg- 
nancy four years previ- 
ously, complicated bj' ex- 
haustion and weakness, 
and delivery of a full-term 
female child after a rather 
long labor. One and a 
half 3 'ears later a “run- 
down” condition was di- 
agnosed as anaemia. A 
persistent cough seemed 
to indicate some lung 
pathologj’. Roentgeno- 
graphic examination, 
however, disclosed no lung 
pathology-, Init a veiy curi- 
ous pathologj- in the bonc.s 
comprising the thoracic 
cage. complete study 
of all the bonc.s of the 
bodv revealed a general- 
ized osteopetrosis. 

vot.. XX. xo. 2, .\rnii. icss 


















484 


H. E. ANDERSON 



Fig. 7 


Tiie patient’s familial histoiy was not remarkable. Her father was living and well; 
her mother died in the early thirties from a heart and kidney disease. 

From the time of diagnosis of osteopetrosis until the patient first consulted the 
author, she had had a number of recurrences of anaemia, which required both intravenous 
and intramuscular medication as well as oral medication. 

On examination, the patient’s skin was rather pale; the size of the head seemed 
larger than normal. There were' a few cervical glands palpable just anterior to the 
sternomastoid muscle. Examinations of the thorax, the heart, and the abdomen were 
all negative. Pelvic examination revealed the cervix lacei-ated slightlj’' and to the left, 
soft, with the typical bluish discoloration of pregnancy. The corpus uteri was markedly 
retroverted and soft, and was estimated to be about the size normally found after two 
months of pregnancy. The blood pressure was 98/62. 

Laboratory findings showed; 

Red blood cells — 5,260,000 
Hemoglobin — 80 per cent. 

Color index— .7; mean corpuscular hemoglobin— 25 micromicrograms 
Mean corpuscular volume — 76 cubic microns 


White blood cells — 12,600 

Polymorphonuclear neutrophiles 65 per cent. 

Large lymphocytes — 2 per cent. 

Small lymphocytes — 32 per cent. 

Eosinophiles — ^ 

Coagulation time— 21^^ minutes; bleeding time— 1 minute 
Blood phosphates-3.34 milligrams in 100 cubic centimeters of blood, 
calcium-8.8 milligrams in 100 cubic centimeters of b ood. 

Uncatheterized specimens of urine showed a trace of albumin a 

blood cells and pus cells. , 

Roentgenographic studies showed a uniform increase in ensi y o i jjneg. 

skull, with obliteration of the medullary spaces, and a loss of ^ 

No mastoid cells appeared; both anterior and posterior f 3) jong 

with no bridging (Jig. 1). The ribs (Fig. 2), all the bodies 

bones (Figs. 4 and 5), and the bones of the pelvis (^^8- ^ ® ‘ medullary spaces, 

in density throughout, with loss of all detail and o 1 er becinning to .show 

The metacarpals, and to a lesser degree the phalanges (Fig. ), 

some of the changes. The diagnosis was osteopetrosis „,.e aereed that 

Inasmuch as this condition is a familial, hereditary iscase, * removal of 

pregnancy i, contra-indicatcd. Foe this rnaaon a M “ 

the foetus and sac intact. Sterilization by resection and hgat.on of the lai p 

THE JOURXAE OF BONE AND JOINT SUROr-R' 




PREGNANCY COMPLICATED B\' OSTEOPETROSIS 


485 


suspension of the uterus, and an appendectomy were done. The patient made an un- 
eventful recovery and has since left the city. 

At the University of Nebraska College of Medicine, microscopic sections of the foetus 
were made, but it was too small to show any important osteogenetic changes. 

DISCUSSION 

The consensus of opinion is that osteopetrosis is a hereditary, familial 
disease, the course of which is chronic, progressive, and unresponsive to 
treatment. 

Pregnancy is contra-indicated; termination of pregnancy and ster- 
ilization are, therefore, advisable. 

BIBLIOGRAPHY 

Albers-Schonberg, H.: Demonstration vor dem aertzlichen Verein in Hamburg. 
Miinchener med. Wchnschr., LI, 365, 1904. 

Holly, L.E.: Osteopoikilosis. A Five Year Study'. Am. J. Roentgenol., XXXVI, 512, 
1936. 

Kudrjawtzewa, N.: Uber Marmorknochenkrankheit. Arch. f. klin. Chir., CLIX, 
658, 1930. 

McCunt;, D. J., ANn Bradley, C. : Osteopetrosis (Marble Bones) in Infant. Review of 
Literature and Report of Case. Am. J. Dis. Child., XLVIII, 949, 1934. 

McPeak, C. N. : Osteopetrosis. Report of Eight Cases Occurring in Three Generations 
of One Family. Am. J. Roentgenol., XXXVI, 816, 1936. 

Pirie, a. H.: The Development of Marble Bones. Am. J. Roentgenol., XXIV, 147, 
1930. 

tVoRTis, H.; Osteopetrosis (Marble Bones). Am. J. Dis. Child., LII, 1148, 1936. 


'■OI.. XX. NO. 2. APRIL ni.l' 



TRAUMATIC MALACIA OF CARPAL BONES 
A Case Report 

BY C. W. BRAINARD, M.D., BATTLE CREEK, MICHIGAN 

Repeated trauma may result in alterations in the carpal bones which 
simulate the clinical changes in the forefoot in the so-called “march foot''. 
Kohler has given a lucid description of the roentgenographic changes 
present in the lunate, occasioned by occupational compression injuries. 
This was first described by Kienbock in 1910, and is designated traumatic 
malacia, or Kienbbck’s disease. 

CASE REPORT 

O. M., wliite, male, aged tu’enfcy-eiglit j^eaz-s, a mill worker, was seen on August 13, 
1934. He stated tliat five daj^s prior to examination lie had noticed a painful swollen 
left wrist. There was no history of accident, and his general health was excellent. The 
usual home treatment had been instituted with no success, and increasing pain and 
swelling caused him to seek medical advice. 

Questioning brought out the fact that the patient’s occupation consisted of keeping 
the flow of corn tlu'ough a pipe in the floor of a bin from interruption by clogging. This 
was done with a metal bar, tamping the kernels through the opening of the pipe, the im- 
pact of the blow being at the base of the palm, and was estimated by the patient to be as 



Tin-: JOI'R.N'AL OF HO.Xi: ANIJ JOINT .‘U. 


4S6 




TRAUMATIC MALACIA OF CARPAL BONES 


487 


frequent as twenty times 
an hour. This occupation 
had been followed for two 
years before the onset of 
sj'mptoms. 

Examination was es- 
sentially negative except 
for the left wrist which was 
swollen and tense, more 
particularly on the dorsum, 
with no evident redness or 
heat. Motion was limited 
and painful, particularly 
in palmar flexion. Palpa- 
tion elicited extreme pain 
on both dorsal and palmar 
surfaces with no evident 
localization. 

Roentgenographic ex- 
amination (Fig. 1) showed 
a loss of the contour of the 
carpometacarpal articu- 
lations of the lesser mul- 
tangular, the capitate, and 
the hamate, and a decalci- 
fication of the distal bor- 
ders of the carpals and the 
proximal ends of the metacarpals. In comparison with roentgenograms of the right wrist, 
those of the left wrist showed an osteoporosis of all of the carpal bones, particularly the 
navicular which showed a small area of cystic degeneration on its mesial border. 

Treatment consisted of immobilization in a circular cast with tlie wrist in the cock-up 
position. The swelling and pain disappeared in a relative^ short time, and in six weeks 
a cock-up splint was applied. Improvement was gradual, pain in palmar flexion being 
the last symptom noted, and, on December 3, a further roentgenographic study (Fig. 
2) was made, which showed a complete restoration of the joint surfaces. The decalcifica- 
tion process was arrested and bonj' trabeculations were evident throughout the bodies. 
The cystic degeneration of tlie navicular was not in evidence, and complete restoration 
of the bony contour was noted. 

The patient returned to his former occupation with directions as to the proper use of 
his hand and wrist, and has had no return of symptoms. 

This condition can well be due to compression injurie.s, producing a 
disturbed nutrition of bone similar to the repeated trauma of inordinate 
weight-bearing which is thought to cause the painful swelling of the fore- 
foot in the so-called “march foot ”, with its attendant bone changes in the 
metatarsals. In this case immobilization was sufficient to effect relief of 
symptoms, and the roentgenographic appearance was such as to warrant 
an optimistic viewpoint as to the ultimate complete recovery. 

REFERENCES 

Kienbock, R.: Ueber traumatische Malazic dcs Moiulbcins uiid Hire Folgczu^taiide: 
Entartung.'jformcn und Kompression-sfrakturen. Fort.'^chr. a. d. Gcb. d. Runtgen- 
strahlcn, XVI, 77, 1910. 

IvonLErt, ALn.\N: Rontgcnologj'; The Borderlands of the Normal and Early Patholopcal 
in the Skiagram. New York, tVm. Vood A Co.. 192S. 



Fig. 2 

Roentgenogram showing complete restoration of the joint 
surfaces. The decalcification process has been arrested and 
bony trabeculations are evident throughout the bodies. 


vot., XX. xo. c. Aniii. I'.i.i'' 




MULTIPLE CONGENITAL DISLOCATION 


BY M. KAMEL HUSSEIN, F.R.C.S. (eNG.), M.CH. (oRTH.), 
CAIRO, EGYPT 


From Kasr-El-Aini Hospital 


Congenital dislocations are extremely rare in Egypt. During the 
course of several years a large hospital may adrnit only one or two patients 
with congenital dislocation of the hip. As often happens when a disease 
is rare in a locality, the cases encountered are often of the severer types. 
Among the very few cases seen, the majority were bilateral, and congen- 
ital dislocations of both knees were as common as those of both hips: 
whereas in other countries the former lesion is extremely rare as compared 
with the latter. The rare types of congenital dislocations occur about as 
frequently as in other countries. No explanation is forthcoming. 

The following case is sufficiently unusual to warrant its being reported. 


The patient, a girl, was seen about a week after birth. 



Fig. 1 

Multiple congenital dislocations. Both hips, knees, and 
tibiofibular joints (proximal and distal) are dislocated. 


4SS 


THE JOUR-VAL OF 


There was nothing abnormal 
in the delivery and a previ- 
ous child was perfectly 
healthy. No other mem- 
bers of the family had ever 
had any similar trouble. 
Roentgenographic exami- 
nation (Figs. 1 and 2) 
showed dislocation of the 
hips, the knees, the tibio- 
fibular joints, the elbons, 
the radio-ulnar joints 
(proximal and distal), and 
the shoulders. Correction 
of the knees was started at 
once, with definite im- 
provement in a month. 
The patient died at about 
the age of three months 
and was reported to have 
had a veiy indefinite lump 
in the abdomen. 

Apart from its in- 
terest as a very rare 
condition, this case is 
such as to cause one to 
reconsider the etiology 
of congenital disloca- 
tions. Abnormal posi- 
tions can hardly be ex- 
pected to separate the 

nO.VE AN-D JOI.VT SURGKRY 



MULTIPLE CONGENITAL DISLOCATION 


489 



• i 




Fig. 2 

Multiple congenital dislocations. Both shoulders and radio-ulnar joints (prox- 
imal and distal) are dislocated. 

radio-ulnar and tibiofibular joints. It seems very likely that there is 
an inherent defect in the mesenchyme which causes such multiple and 
universal lesions. 


vou XX. NO. Arnii. it>3s 



FRACTURE OR EVULSION OF THE ANTERIOR SUPERIOR 

SPINE OF THE ILIUM 

BY E. N. CLEAVES, M.D., BOSTON, MASSACHUSETTS 

Fracture or evulsion of the anterior superior spine of the ilium is not a 
very common occurrence. According to Dr. Voigt Mooney of Pitts- 
burgh, there have been fifty-eight cases reported. Dr. Mooney added 
two more cases, bringing the total to sixty. The author wishes to report 
two cases which have come under his observation. 

Case 1. T. W., a well-dcveloped, wlu'te boy, eighteen j’-ears of age, u’as playing 
touch football on November 14, 1935. He caught a pass and ran seventy-five 3 \ards, 
when he felt pain in the right groin. He had e.vperienced similar pain before, and had 
called it “a muscle pull”. The pain persisted for seveial days, and then completely dis- 
appeared. On November 22, he felt entirely well, and again played touch football. He 
received a kick-off and mn eighty yards to the goal line. Just at the goal line, he felt a 
“sudden crack” or “sense of something giving way” on the rightside in the region of the 
anterior superior spine. His leg buckled under him and he fell, landing on the left hip. 
There was immediate marked pain in the right side of the pelvis and the right leg. Tlic 
patient got up, walked around with a limp, but continued in the game for about twenty 
minutes, although he did not run. After taking a shower, the patient tried to go down 
some steps, and felt very acute pain. He then had to be carried to the infirmaiy, where 
he was placed in a plaster spica. He had an uneventful recovery in from six to ten weeks. 

Case 2. T. S., a well-developed, white boj’-, seventeen 5 Tai-s of age, was injured by a 
sudden twisting motion, while pla.ying football. Thei’e was no direct violence. Acconi- 



Fig. 1 
Case 1 


490 


the jounxAL of hoxe axo 


joi.vT si’noi;u% 



ANTERIOR SUPERIOR SPINE OF THE ILHJil 


491 



Fig. 2 
Case 2 


panj'ing the twist, there was sudden, severe pain in front of the hip. Tlie patient was 
able to walk, although with some degree of discomfort. Treatment consisted of the ap- 
plication of a figure-of-eight bandage; no plaster was used. An uneventful recovery 
followed. 

These two cases are typical of this lesion. It usually occurs during 
adolescence, in boys or girls who are engaged in athletics. The patient 
experiences sudden severe pain in the region of the anterior superior spine 
of the ilium, following strenuous muscular effort or a sudden unguarded 
movement. The roentgenogram is quite tiqiical. Complete recovery is 
the usual result. 


VOI.. .\.\. NO 


.M-nii. Ills 





169/36 Male 35 Left tuber ischiiYes Yes Yes Partial subperi- Healed Tuberculosis Healed 
and superior ramus osteal resection 

of the ischium of the tuber is- 

chii and the su- 

I perior ramus 

























































FRACTURE OF THE FIRST RIB 


493 



Fig. 1 

W. R. Roentgenogram on admission, showing fractures of the first ribs without 
any alteration of alignment. 


of the right side of the second thoracic vertebra was also recorded in the report of 
this roentgenogram. 

The treatment consisted merely of rest in bed for tliree weeks without any type of 
fixation, and, after an additional week in the hospital as an ambulatory case, the patient 
was discharged on the twentj’-eighth day after the accident, symptom-free and with no 
demonstrable physical signs relating to his injuries. He was seen about seven weeks 
later on a return visit to the Clinic and at this time had no symptoms or signs referable to 
the fractures. 


REFERENCES 

Bresun, F. J.; Fractures of First Rib Unassociated with Fractures of Other Ribs. 

Am. J. Surg., XXXVIII, 384, 1937. 

Lane, W. A.: Quoted by Breslin. 

Rebhorn, E. H. : Horner’s Syndrome. Caused by Fracture of the First Rib. Bull. Moses 
Taylor Hosp., II, 77, 1933. 


VOU XX. NO. 2. ArniL IP3S 


FRACTURE OF THE FIRST RIB UNASSOCIATED WITH 
FRACTURES OF OTHER RIBS 

A Case Report 

BY TOM OUTLAND, M.D., F.A.C.S., AND C. R. HANLON, M.D., 

SAYRE, PENNSYLVANIA 

Ft 07 )} The Guthi’ie Clinic, The Fohcrl Packer Hospital, Sayre, Pennsylvania 

Fractures of the first rib are stated to be very rare by most texts and, 
as a matter of fact, are seen veiy infrequently in routine traumatic work. 
Recently Breslin has reported five cases of fracture of the first rib with a 
review of twenty-seven other cases which he found in the literature, along 
with a discussion of the anatomy, mechanism, pathology, symptoms, com- 
plications, and treatment. He emphasizes the fact that, although frac- 
tures of the first rib are rare, their presence should be considered in patients 
who complain of a "sticking pain” in and around the shoulder region, 
particularly in those patients who, after severe trauma, do not show signs 
of fracture of the neck, clavicle, or humerus. 

Regarding the mechanism, Lane, the English anatomist, has sug- 
gested that fracture of the first rib may occur only in one of three ways : 
(1) as the result of indirect violence, the force being transmitted through 
the clavicle; (2) directly by means of force applied behind; or, (3) indirectly 
by force transmitted through the manubrium. 

Fracture of the first rib is important because serious complications 
are liable to develop. The most significant of these are : (1) abscess forma- 
tion above and below the clavicle; (2) rupture of the apex of the lung; 
(3) emphysema; (4) pleurisy; (5) hemoiThage; and (6) nerve symptoms 
which may come on immediately or a few months after the accident when 
the callus is of sufficient size to encroach upon the nerve pathways. 
Rebhorn reported one interesting complication of fracture of the first rib, 
namely, the development of Horner’s syndrome in a male, twenty-one 
years old, who had suffered a squeezing violence to the upper part of the 
chest. 

Because of the rarity of this fracture and the complications which 
may develop, the authors Avish to record the following case. 

W. K., male, twent3"-one years of age, was recently admitted to The Guthrie Clinic 
in shock, having been pinned in the rumble seat of an automobile when tlic car ha 
crashed into a post. He complained of backache, inability to move tlie left arm, an 
difficulty in breathing. Respirations on admission were 48 per minute. Active or pas 
sive attempts to flex the neck caused great pain. Expansion was limited bilatera j on 
admission and many coarse rales were heard over both lung fields on auscultation. ic 
patient did not complain of pain on deep inspirations. * i i 

The roentgenogram taken after admission (Fig. 1 ) showed fractures of t le ver c wa 
ends of both first ribs with no displacement of the fragments. A fractuie of t le amin.i 

400 THE JOUnX'AL or nON'E AN'O JOIN'T SI nf.Kin 



A COMPACT PENDTJLTOI ARTHROMETER 


495 


axis of the bearings 
should be vertical to 
the face of the lid, so 
that the pointer does 
not scrape the dial 
any^vhere in its trav- 
els. The rear end of 
the axle must not be 
so long as to bear on 
the inside of the box 
when the lid is pressed 
into place. 

The weight of the 
completed instrument 
is about three ounces. 

In use (Fig. 4) the instru- 
ment is strapped to the part 
distal to the joint to be meas- 
ured, and the limb is arranged 
so that rotation about the 
joint occurs in a vertical plane. 

The parts are fixed at any- 
given angle (straight, at a 
right angle, etc.) and the dial 
is set at a corresponding read- 
ing by twisting the lid on the 
box. The operator then fixes 
the part proximal to the joint 
with one hand while he steadies 
the instrument and guides the 
patient with the other. Care 
must be taken to see that the 
muscle and soft-tissue movements do not cause the instrument to 
rotate slightly on the part. Tlie measuring proce.ss should be repeated 
two or three times until the operator is satisfied tliat he has an accurate 
reading. 

The instrument has been especially useful in determining the return 
of elbow-joint function following fracture of tlie lower end of the humerus, 
i)ut with more or less ingenuity it can be used for most of the otlier motions 
of the body. 



Fig. 4 


Showing the use of the artlirometer to indicate 
the range of motion in the elbow joint. 



Fig. 3 


The parts of the artlirometer. An extra pointer has 
been included to show the shape of the wire without the 
lead casting. 


VOI,. XX. XO. .U’Utt. t!>'S 




A COMPACT PENDULUM ARTHROMETER 

BY JOHN G. HAND, M.D., PHILADELPHIA, PENNSYLVANIA 


The commercial instrument for measuring the range of joint motions 
designed in 1918 by Falconer is unsatisfactory for use on children and on 
small adult joints, because its weight makes it unwieldy and difficult to 
use accurately. However, such an instrument is of great value in measur- 
ing the motions of the extremities, and a comiJact model will be used daily 
in the clinic because of its ease of application and rapidity of use. 

Excellent service has been obtained in two fracture clinics from a 
small home-made instrument (Fig. 1) which is readily fitted to a young 
child's forearm, hand, or foot. It is made from an ointment box and is 
constructed without technical finesse, as follows : 

A one-ounce ointment box is fastened to a strap by riveting, or 
construction of a metal slot soldered to the back, as shown in Figure 2. 
A dial, graduated in 5-degree units, half reading clockwise and half 
counter-clockwise, is glued to the label. (This may be made accurately 
bj’' photographing to scale a large dial which has been carefully drawn, 

and using a print of this 
photograph.) 

A pendulum is then con- 
structed by casting about 
thirty grams of lead in a 
quadrant-shaped mold and 
incorporating a piece of steel 
music wire, bent as shown in 
Figure 3. The caliber of the 
wire is about five-hundredths 
of an inch, and the wire serves 
as an axle for the weight and 
as an indicator for the dial. 
The indicator arm should be 
ground to a point and painted 
black. 

The pendulum-pointer 

unit is pa.'sed into a hole, drilled 
in the center of the lid of the 
ointment box, from within, so 
that the pointer is outside, 
the weight inside, and the 
unit hold in this position by a 
bearing made of tin, soldered 
to the back of the lid. The 



Fig. 1 

The arthrometer. 



Fig. 2 


Rear view of case, showing attachment of strap; 
and inside of lid, showing mounting of pendulum. 


494 


the JOURN'At OF BONE 


and joi.vt .simoiati 




SKELETAL TRACTION TO THE DIGITS 


497 



Fig. 1 


both in regard to efficiencj'^ and the patient’s comfort. In addition to 
oblique fractures and some transverse fractures of the long bones of the 
hands and feet, fracture-dislocations of the interphalangeal joints have 
also been reduced and the position has been maintained. In many cases 
of badly comminuted Colles’ fracture, better results can be obtained with 
traction which can easily be applied bj"^ this method through the thumb or 
the index finger. 


VOI.. X.X. .VO. 2. .M’niL I03S 



A METHOD FOR SKELETAL TRACTION TO THE DIGITS 

BY G. MOSSER TAYLOR, M.D., AND ALONZO J. NEUEELD, M.D., 

LOS ANGELES, CALIFORNIA 

From the Department of Orthopaedic Surgery, College of Medical Evangelists 

TJie use of skeletal ti'action has I'apidJy become an accepted procedure 
in the ti eatment of fractures. Its application to the fingers has progressed 
somewhat more slowly. Too often the size of the transfixing pin is out of 
pi oportion to that of the phalanx. There is also the problem of how best 
to fix the traction to the pin. For these reasons the less complicated 
methods for applying traction to the fingers — such as adhesive plaster, 
celluloid dressings, fingernail traction, and pins through the pulp of the 
finger tip ha^'•e been in Amgue. The most efficient, as well as the most 
comfortable type of traction, especially where considerable pull is neces- 
sary, is that applied directly to bone. More general use of skeletal trac- 
tion to the fingers and toes would no doubt result were there an easy and 
simple method of application. 

The apparatus which the authors have devised for this purpose con- 
sists of a wire of minimal size, an ordinary small Yankee drill such as may 
be purchased in any notion store, and a simple C clamp. The wire is 
stainless steel of the smallest size — 8-gage piano wire such as is usually sold 
for the Kirschner outfit. This wire is cut to appropriate lengths and on 
one end of each is made a drill point. Tonsil-snare wire may be used, but 
of course this is not stainless. The drill is a cheap variety of the Yankee 
drill. A small tunnel may be made deep to the chuck to take up further 
length of the wire. When using the drill it is better to employ an alter- 
nating motion than to keep jerkily trying to turn it in a continuous cir- 
cular manner. The C clamp is made of 8-gage spring-steel wire. Each 
prong is drilled one-sixteenth of an inch from the end in the a.xis common 
to both prongs a little larger than the wire it is to receive. The wire maj^ 
be inserted through any phalanx, but in general a point should be used as 
close as possible to the lesion. 

After the skin has been sealed with tincture of benzoin and gauze, the 
ends of the wire are cut to the required length and turned back 180 de- 
grees with a Kelly clamp or a prong of the C clamp itself. The wire is then 
ready for the application of the C clamp which supplies the tension to keep 
the Avire taut. This is facilitated by the use of a pair of ordinary slip-lock 
pliers or medium-sized hemostats to hold the tension of the C clamp while 
hooking it onto the wire. The manner of hooking the lA'ire is shovn in 
Figure 1. In turn, traction is made on the clamp through nibbcr bands 
Avhich are secured to the usual banjo splint or to a liookcd ivire embedded 

in a plaster cast. i i g . 

This method of appljdng traction to the digits has been used ly a, 

authors during the past tAvo years, and has giA^cn entire satisfaction 

THE JOUnXAL OF HON'E AXD JOI.N'T .SCKOFEA 


496 



FRACTURES OF THE TIBIAE COXDYLE 


499 



Fig. 1-A 

Lateral roentgenogram showing frac- 
ture extending diagonally from the distal 
margin of the tibial tuberosity into the 
subchondral cortex. 


Fig. 1-B 

Anteroposterior roentgenogram show- 
ing elevation of the floor of tlie lateral 
portion of the knee joint. 



Lateral roentgenogram sliowing firm 
union, witli preservation of the cpipliys- 
eal line in the posterior part. 


I ■■■— '■■IP'— 





Fig. 2-li 


Antcroix)>forior roentgenognun show- 
ing normal alignment. 


remained seemed a bit dubious. I’lwm cxjxisure, a large amount of don^c vj-.-m 
tissue, completely covering the fragment, was found. Whether this wa- evolvisj fnuii 
the periosteum, from the joint eap-ule, or from the .surrtiunding ligament- wa- not de- 
termined. The layer of tissue wa- the tliirkne-s of the little finger and -'-tnud to jin-ent 


VOI.. XX. NO g. .M'UII. 1P.1S 






THE USE OF PERIOSTEAL SUTURES” IN OPEN FIXATION 
OF FRACTURES OF THE TIBIAL CONDYLE 

Report of One Case 

BY LESTER E. GARRISON, M.D., F.A.C.S., AND MONROE GARRISON, M.D., 

CHICAGO, ILLINOIS 

From the Surgical Dittision of Afercy Hospital, Chicago 

It is the iDurpose of this report to call attention to what might be 
termed a variation of technique in the operative fixation of condylar frac- 
tures of the tibia. The method was discovered somewhat by accident. 
It will not be applicable to every case, especially to those in which there is 
a gap between the fragments. Where it can be used, it represents a rapid 
and easy means of procedure. It greatly shortens operating time and may 
prevent the rarefaction of bone that too often follows pin or nail insertion. 
It should not be overlooked in cases that present a patent epiphyseal line. 

This technique has been termed the use of “periosteal sutures” 
largely because of lack of a better name. 

CASE REPORT 

F. K., male, aged fifteen, was admitted to the Surgical Service of Mercy Hospital on 
March 26, 1935. On the previous day he had fallen while running, striking the right 
knee and thigh. He did not recall whether or not the knee had been wrenched. It had 
been impossible for him to bear weight on the leg immediately after the accident. Swell- 
ing had followed at once and, according to the patient’s description, it e.xtended from the 
knee to the ankle. 

Examination at the time of admission showed the right knee, lower thigh, and upper 
leg to be markedly enlarged. A large hematoma was present over the tibial tuberosity 
and smaller hematomata were scattered about the knee joint. Bony landmarks were 
obliterated. Because of the great swelling and tenderness, accurate palpation was im- 
possible. After incorporation of the limb in a posterior metal splint, anteroposterior and 
lateral roentgenograms were taken. 

The lateral roentgenogram (Fig. 1-A) showed a fracture extending diagonally from 
the distal margin of the tibial tuberosity into the subchondral cortex. The fragment 
was wedge-shaped and included most of the tuberosity. It had been tilted upward by 
the action of the quadriceps, displacing the patella above the intercondylar groove. The 
fracture line had followed the growth cartilage and had then broken into epiphyseal hone. 
The anteroposterior roentgenogram (Fig 1-B) showed elevation of the floor of the lateral 
portion of the knee joint. The fibula was uninvolved. 

The position of the fragments and the displacing force exerted by the upward pull of 
the quadriceps indicated an open reduction. It was thought advisable to wait for a few 
days to allow the swelling to decrease. Accordingljq the extremity was immobilificd in a 
short plaster spica to minimize muscle pull. It was hoped that complete avulsion of the 
fragment might be prevented. During this time, complications developed. The par- 
ents refused to believe that a “broken bone’’ required surgeiy. As a result, operation 
was not performed until April 9, or two weeks after the injury. 

Under anaesthesia, the knee was again palpated and the fragment was found to le 
entireh’’ lateral!}'. Crepitation was pronounced. That attachment to the shaft }e. 

. 498 THE JOURN'AU OF BONE A-VD JOINT 801101.111 



table II 

Cases of Osteitis of Septic or Uncertain Origin 


TUBERCULOUS OSTEITIS OF THE ISCHIUM 


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VOL. XX, XO. 1. JANUARY 193S 



500 


L. E. GARRISON AND M. GARRISON 


an excellent means of fixation. The fragment was replaced with a mallet. Two mat- 
tress sutures of No. 2 chz-omic catgut were placed through the scar tissue, each in an 
opposite direction to equalize the pull, and snugly tied. Upon inspection it was seen 
that normal alignment of the bone was again established. The wound was closed in the 
routine manner. A long spica cast was applied. 

Recovery was uneventful. The patient was discharged on crutches on the nintli 
postoperative day. Four weeks after operation, the spica was removed and a long leg 
cast was applied. This second cast was removed in three weeks and the patient was told 
to use the leg as desired. He was seen again in two weeks, nine weeks from the time of 
operation. Active flexion to 90 degrees was possible. Passive flexion was not at- 
tempted. There was complete extension, but lateral rotation of the foot and leg was 
limited. 

The patient was told to return in one 3 mar. He was next seen on July 3, 193G, at 
which tizne a second sei-ies of roentgenograms was taken. The lateial roentgenogvam 
(Fig. 2-A) showed complete and firm union, with preservation of the epiphyseal line in 
the posterior part. The anteroposterior view (Fig. 2-B) revealed normal alignment. 
The former line of fracture was indistinct. All motions were complete. The patient 
walked well, with complete absence of limping and pain. 

DISCUSSION 

The report of these rather unusual findings is presented in the hope 
tliat it may be of value. We have been unable to find a similar technique 
in the literature. The formation of anomalous tissue and the ease of 
operation make one think that it may be advisable to wait ten days or two 
weeks in all open reductions of fractures of this type. 

The derivation of the scar tissue is in doubt. Most probably, it came 
from the fibrous layer of the periosteum. We confess negligence in not 
obtaining a piece for microscopic examination, but whether or not tins 
would have revealed any clue as to the origin remains debatable. 

We hesitated to use pegs or nails in this operation because of the 
evident patency of the epiphyseal line. Adequate fixation could probably 
not have been obtained without piercing the growth cartilage. Although 
the boy was large and evidently had attained full stature, the upper tibial 
epiphysis does not completely ossify until the age of nineteen at least. 
Trauma to a center of possible future growth is surely not compatible with 
the best surgical technique. 

During a recent bit of research (under the direction of Dr. Ed^yard L. 
Compere of the University of Chicago), it was discovered that drilling the 
upper femoral epiphyses of experimental animals caused distortion of 
growth, sometimes so slight as to be visible only on the dissected spcci 
men. Insertion of bone pegs or chips resulted in a more serious disturb- 
ance of growth with greater deformity, while curettage of the cpiphysoa 
margins gave what might be. called the maximal deformity. 

Because of these findings, it was concluded that all .surgical manipula- 
tion in the region of active epiphyseal lines is to be avoided. 


THE JOURNAL OI’ BONE 


AND Joi.vT .suitorao 



A SIMPLE TECHNIQUE FOR INSERTING THE 
SMITH-PETERSEN NAIL 


BY DON KING, M.D., F.A.C.S., SAN FRANCISCO, CALIFORNIA 

From the Stanford University Surgical Service, San Francisco Hospital Unit of 
San Francisco Department of Public Health 

The following simplified technique has been found to be practical and 
accurate and has been used in thirty femoral-neck fractures. The results 
have proved that roentgenograms fol- 
lowing manipulation, complicated pro- 
tractor apparatus, and preliminary in- 
sertion of guide wires are unnecessary. 

The nail length required is cal- 
culated asfollows : Alead tape, threeand 
one-half inches long, is fastened to the 
skin just below the greater trochanter 
of the normal hip and a posterior roent- 
genogram (Fig. 1) is taken. Since the 
lead tape and the femoral neck are 
about the same distance from the 
film, the amount of distortion is the 
same, and hence it is easy to figure 
the length of nail needed. 

The patient is placed on an ordi- 
nary operating-room table, with the 
pelvis resting on a cassette box (Fig. 2), 
and the fracture is reduced ( Leadbetter 
technique). A^o check-up 
roentgenograms are neces- 
sary. With the extremity 
held in abduction and inter- 
nal rotation, a four-inch in- 
cision is made, and t he origin 
of the vastus lateralis is ex- 
posed and divided for a di.s- 
tance of one inch. A long, 
stiff wire, bent to the shape 
of a normal femur, is laid 
over tlie lateral aspect of 
the thigh. The nail is 
driven in jiarallel to the 
short arm of the wire and 
tile floor (Fig. 2). An an- 



Fig. 1 

Tracing of roentgenogram with lead 
tape, three and one-half inches long, on 
skin. 



Fig. : 


tcroiiosterior roentgenogram 
VOL. XX, NO. c. .\rntL ims 


Cad.avcr re-ting on ea— ette box; angle wire in 
place indicating position of the neck and shaft: nail 
iicing driven in parallel to sliort arm of wire and flisir. 

.■)01 


fliF* riGlLT moircrt. 




502 


J. S. STEPHENS 


is then taken. AVithout moving tlie tube, the thigh is flexed 90 degrees. 
As it comes up into flexion, it is allowed to fall into moderate abduction 
and external rotation. Another roentgenogram is taken, which is a 
lateral projection. If the direction of the nail needs to be changed, the 
nail is extracted and reinserted. 


AN INEXPENSn^E, DURABLE AVALKING CAST 

BV JOHN S. STEPHENS, M.D., LOS ANGELES, CALIFORNIA 


By placing a short section of scrap tire on the bottom of a Bohler-type 
walking east for an adult or child, one can obtain a soft, durable, non-skid 
surface for weight-bearing that is not characteristic of the commonly used 
strap-iron crutch heel. 

Figure 1 shows a cross-section of an automobile tire. The outer 


tread, the rubber side wall, and 



the bead have been cut away. The 
uncut half is shown for comparison. 
Figure 2 shows the flexible side wail 
incorporated in the completed cast 
with layers of plaster. 



Fig. 2 


One should use the smaller type of tire with a thick, unused tieac . 
The wire beads should be removed before the tire is cut into segments n it i 

a sharp oiled or ^vet knife. , 

A defective or scrap tire with the beads removed can be purcha-f fi 

for a few cents and can be cut into approximately foity sections, n a » 
the cost negligible. 


THE JOO'U.N’AE OF HO.Vi; A.vo JOI.VT .si nc.l.l.' 



A MODIFICATION OF THE TRACTION TREATMENT OF 
SACRO-ILIAC STRAIN 


BY ALLAN H. WARNEE, M.D., WOODSIDE, LONG ISLAND, NEW YORK 

In the treatment of sacro-iliac strain and sciatic syndrome, it is some- 
times desirable to maintain traction of one or both lower extremities. 
This is usually done by Buck’s extension, attaching a pail of lead shot to 
the foot through a projecting pulley arrangement. 

Since traction need not alwaj^s be continuous, the patient is ordi- 
narily permitted to get up for bowel movement, and may be allowed other 
periods of relaxation. The patient cannot con^"eniently get in and out of 
the lead-shot and pulley arrangement ivithout help, and it is desirable to 
have an apparatus which the patient can handle without any assistance. 

The following contrivance has been found simple, convenient, and 
practicable for home treatment. 

The inner tube 
of a tire is placed 
around the footboard 
of the bedstead at the 
level of the upper sur- 
face of the mattress. 

Two loops, about eight 
inches in diameter and 
made of canvas tape 
or a trouser belt, en- 
circle the inner tube 
perpendicular to its 
length, between the 
rungs of the bed- 
stead. The feet of 
the patient are placed 
in the loops, so that 
the tape hooks above the ankles, the ealeaneal tubercles, and the toes. 
The two loops are about eighteen inches apart. 

The foot of the bed is elevated into reverse Fowler’s position, and the 
Jiationt pulls himself toward the dejiendent head of the bed sufficiently to 
ajijily tension on the rubber inner tidie. In this way. the jiatient’s body 
weight opposes the pull of the inner lube. 

This position can be maintained for horn’s at a time without dis- 
comfort to the patient. It will usually be found neee.ssary for the jjatient 
to inill himself to the head of the bed every once in a while, as the inner 
tube jnills him the other way. 





Fig. 1 

Showing the strap in position. The strap is prevented 
from slipping by the fonvard projection of tlic tarsal hone.s 
and tlic backward projection of the os calcis. 


vui. w. xo, j. Arnii. icr.'. 



A SCREW FOR OBLIQUE FRACTURES 

R. M. lERGASON, M.D., P.A.C.S., HARTFORD, CONNECTICUT 

Who has not had difficulty in maintaining reduction of oblique frac- 
tures of the tibia? No matter how well these fractures may be reduced 
and splinted, the calf muscles -are so strong that either the fragments slip 
into overriding or the long superficial point of one fragment is caused to 
project under the skin by angulation due to spasm in the muscles. 

To meet this annoying situation, the author has used the Carrell- 
Girard screw, which was found to be quite effective; nevertheless, the 
wood-screw point did not always hold well in the bone, and the selection 
of the proper drill to use was difficult as the screws vary in size. Further- 
more, the thickness of the bone cortex is onR'’ sufficient to contact two or 
three turns of the wood-screw thread, and, in consequence, the grip of this 
screw is unsatisfactory. It, therefore, occurred to the author to combine 
the idea of Carrell and Girard with that of Sherman. The Sherman 
screw has a tap point and machine thread, and the tap point cuts its own 
thread in the bone. A machine thread, having a much smaller pitch than 
that of the wood screw, brings a number of turns into the cortex, so that 
the grip is much stronger. 

The screw illustrated in Figure 1 can be procured, cadmium-plated,* 
at any hardware store, and the cost is negligible. The tap point is easily 
added by a few strokes of a fine file, and two nuts may be placed upon it 
in the way in which Carrell and Girard use them. 

A curved incision exposes the fracture. The ends of the bones are 
cleaned and placed in perfect apposition, and held there by any form of 
bone-grasping forceps (those used by the author are a simple pair of tongs 
made with flat, curved jaws to grasp the bone). The tongs are held by an 
assistant. The hole in the superficial cortex is made with a drill just 
large enough to allow the screw to slip through. The deep cortex of the 
other fragment is drilled through the same hole with a drill slightly 
smaller (the size of the drill is determined by the diameter of the screw 
less its thread). The screw is then inserted and made to engage in the 
deep cortex by turning it in with a small screw driver; six to eight half 
turns are sufficient to get a very strong hold in the deep cortex. By 
means of a tubular wrench, the two nuts are then turned down upon the 
superficial cortex, one locking the other. The bone-holding forceps are 
removed, and the wound is closed, allowing the screw to project. The 
nuts, of course, are buried below the skin, but in the case of the tibia they 
are quite superficial. The screw is buried in the sterile dressings, anc 
only a light molded plaster splint is necessary. ^ 

The patient is allowed up on crutches as soon as swelling has su i- 

* Cadmium plate seems to be well tolerated by the tissues. Two screws which have 
been in a femur for three months look unused. 

the journ'al of no.vE a.vd joi.vt stmormi 



SCREW FOR OBLIQUE FRACTURES 


505 



Fig. 1 

Showing the three common sizes of screws with their appropriate drills in clips for 
convenience in boiling, tubular wrenches, small screw driver, and rectal speculum. 
The two lamb bones illustrate the appearance of the screws in place. 

sided, which may be in two or three days after operation. The patient 
may be discharged from the hospital in a short time and ma3' come on 
crutches to the office for the removal of stitche.s. After from two to three 
weeks, when sufficient callus has appeared and healing of the soft parts 
about the bone has taken place, the screw may be removed with ease. 
It will be found necessary to turn the screw out of the deep corte.x, which 
will probably require the use of an artery clamp. Three or four turns loosen 
the screw from the deep corte.x and it can then be withdrawn with the 
fingers. In such a short time as three weeks the wound will not have 
healed around the screw so tightly as to make difficult the withdrawal of 
the screw bearing the nuts. 

The author has used this screw in .situations where, the nuts being 
deeply covered by soft parts, the skin has healed around the screw closely, 
requiring a little nitrous-oxide anaesthe.sia to ojien the wound slighth' 
and thus facilitate removal of the screw. 

In fractures of the femur, wlien the line of fracture is toward tlie 
wound, it maj" be best to insert the screw from a diflerent direction. 
For this, a two-inch inei.sion through skin and fascia allows a bivalve rectal 
speculum (Sims-Boteiihainer) to be inserted. The speculum can be 
o])ened enough to permit it to ride astride tlie lione, and through it the 
drilling and insertion of the screw are easil\' aeeoniplished without undue 
trauma to the perforated tissues. Extra long drills (five inches) are neces- 
sary in working through the speeuium. 

Diflerent lengths of the screw lend themselves to oblique fractures of 
the femur. In such a fracture near the knee, the fragments an* verv apt 

voi. x.\. xo. . 


.\I’IIII. I'-lts 



506 


R. M. YERGASON 


to kick out of position by the pull of the gastrocnemius and hamstring 
muscles, and reduction is very difficult to maintain by other methods. 
There is only one point to be carefully observed and that is to make sure 
that the drill which is to be used in the deep cortex is just the right size, 
which is determined by the diameter of the screw less the thread. The 
drill for the superficial cortex may be a bit large, as the nuts will hold the 
screw satisfactorily. At the same time, it is best to have this drill just 
the right size to allow the screw to pass through easily. 

Drills supplied by surgical instrument houses, as well as those from 
hardware stores, all seem to have rather dull points beveled at an angle of 
60 degrees. Such drills slip off the bone or migrate sideways when the 
hole is started. It is a great convenience to have the points reshaped at 
30 degrees, which obviates this mishap. 

This rather .simple open reduction assures perfect maintenance of 
position with a .short period of hospitalization, which markedly reduces the 
period of disability. 

REFERENCES 

Carrell, W. B., and Girard, P. M.; Removable Internal Fi.vation in Fractures. 
J. Am. Med. Assn., XCVI, 670, 1931. ' 

Sherman, W. O’N. : Compound Fractures of the Femur and Open Fractures into Joints. 
J. Bone and Joint Surg., VI, 344, Apr. 1924. 


THE JOURNAL OF BONE 


and joint SURGERI 



SPINAL HYPEREXTENSION LITTER 

BY RALPH D. PADULA, M.D., NORWALK, CONNECTICUT 


The management of fractures of thoracic and lumbar vertebrae in the 
last decade has changed considerably with the advent of newer and better 
methods of transportation. Traffic casualties and disasters have acceler- 
ated the number of crushing injuries and fractured vertebrae. Laymen, 
ambulance drivers, or recent medical-school graduates have little or no 
practical e.xperience in the application of splints, diagnosis, and transpor- 
tation of injured. 

It is the author’s contention that a majority of fractures of the verte- 
brae are not complicated by cord injuries as a re.sult of the accident, but 
complications arise from the improper care in handling these patients 
after the accident. It is a well-known fact that by far the largest number 
of fractures of the vertebrae are produced bj"- forcible hyperflexion of the 
bony vertebral skeleton. This induces compression of the anterior por- 
tion of the bodies of the vertebrae, rvith or without torsion and lateral 
displacement. 

In conveying the patient to a hospital, it is very important to keep the 
back in a hypcrextended position from the time of the accident to the final 
disposition of the case. A patient is moved at least five times from the 
point at which he is picked up to the taking of the roentgenogram. It is 
difficult to ascertain when a fracture, not complicated by paralj'sis imme- 
diatel}’^ after the accident, receives the trauma necessary to cause injuiy to 
the spinal cord. Frequentl}’^ diagno.sis of a broken back is not made until 
paresis of the bladder and paralysis of the lower extremities occur. The 
fracture then can only be definitely determined as a result of a roentgeno- 
graphic examination. The axiom which we believe should be followed in 
the treatment of fractured vertebrae is: “Splint them where they lie.” 

The mobile hyperextension method of transjiortation and treatment 
of the injured causes the patient to be moved only once. I'rcalment with 
this hypero.xtension method consi.sts of forcible reduction of the fracture. 
Some patients, however, are ])laced in a hyiierextended ])osition and 
maniimlated under general anaesthe.'jia. The fracture is then immobilized 
in a plaster jacket or jilaster sjnea. 

For the pa.“:t seven years the writer’s interest in fractures of the thor- 
acic and lumbar vertebrae has been quickenetl, with emjihasis on the a]>- 
lirojiriate trans])ortation, diagnosis, and treatment. Dr. Georg(‘ Hawley, 
of Bridge])ort, donated his wide exjn’rienee in fractures and jjilotefi the 
author through this work. The old adage. “Sj)lint them where they lie", 
was unremittingly emjihasized l)y Dr. William I^arrach, Dr. Clay H;iy 
Murray, and Dr. Barbara Stimson <luring the writer’s residency at the 
Bre.sbyterian Hos])ital. Their views were n'si>onsibIc for his intercut in 
the development of this mobile hyiierexten'-ion frame. 

VOI.. XX. X'O. J. .\PIIIL Ui.T. -.07 



508 


R. D. PADULA 



Fig. 1 


Attachment of suspensory band. 

This hyperextensiou frame was designed and fashioned to be perma- 
nent equipment in all standard ambulances. This table can be safelj'’ 
strapped to the ceiling without detriment to room and efficiency. It con- 
sist.s of a stretcher, a hoisting frame, a lever frame, and a suspensory band. 

Tlie stretcher portion of the frame is seventy-two inches by twenty 
inches and is made of light, chromium-plated, half-inch steel tubings. It 



Fig. 2 

Hvperextension of spinal column. 

TJIK JOl'R.V.AL OF llONK AND JOI.NT S(. KOI. 1.1 


SPINAL HYPEREXTENSION LITTER 


509 


is reenforced on the under side by light steel cross-bars. The ends of the 
horizontal bars are turned in the shape of a U, which makes a r^eiy effec- 
tive hand grip. The upper .surface of the stretcher is made of teakwood, 
one-half an inch thick, and covered with a one-piece removable pneumatic 
mattress. 

The hoisting frame is twenty inches high and twenty inches wide, and 
is made of half-inch chromium-plated steel tubings in the shape of an in- 
verted U, with the twin legs of the U fitting into a specially designed fix- 
ture. Once the hoisting frame is placed in position, it is capable of with- 
standing at least 500 pounds of pressure without being displaced in anj'^ 
direction. The rounded end of the U is a continuation of the twin legs of 
the U, so that it makes a perfect I'eceptacle for the lever frame. 

The lever frame is forty-eight inches long and twenty inches wide, and 
is also made of half-inch chromium-plated steel tubings in the shape of a 
rectangle with the end bar slightly curved. Tliere are two reenforcing 
cross-bars made of the same tubing as the rest of the frame. The anterior 
bar is made to fit into the rounded end of the hoisting frame, premitting 
thirty inches of the lever frame to elevate the suspensory band. 

The suspensory band is made of 18-gage half-hard aluminum sheets, 
this material being chosen because it bends easily to conform to tlic con- 
tour of the body and for the taking of anteroposterior and lateral roent- 
genograms. This band comes in different size.s — eight inches liy twenty 
inches, six by eighteen, and four by fourteen — to be used according to tlic 
size of the jiatient. 

The hyperextension stretcher is taken out of tlie ambulance and car- 
ried to where the injured person is lying. The susiiensory band is sliiiped 
under the small of the back, iirodueing a moderate amount of liyperexten- 



510 


K. D. PADULA 


sion. AVith the hyporextension maintained, the patient is gently placed 
on the stretcher portion of the frame. The hoisting frame is fixed in posi- 
tion on the stretcher. The lever frame is placed in position in the hoisting- 
frame. The suspensory band is attached to the lever frame and, by pres- 
sure on the posterior portion of tlie lever frame, the required amount of 
hyporextension is produced and maintained by locking the strap between 
the lever frame and the stretcher. The patient on the hyperextension 
frame is very easil}'- transported to the ambulance in much the same wa}'- 
that he would be carried on any other .stretcher. 

SUMMARY 

1. The same consideration should be given to fractures of the spinal 
column as to fractures elsewhere in the bod 3 ^ Restoration of normal 
bone-and-joint contour of fractured vei’tebrae is just as essential to restora- 
tion of normal function as it is in fractures elsewhere in the bod}^ 

2. Fractures of the vertebrae without cord changes can easily be 
converted into fractures with cord .symptoms by improper handling and 
transportation of a patient to the nearest point where a diagnosis and 
competent treatment can be obtained. 

3. Splinting of fractured vertebrae where the patient lies is just as 
important as splinting fractures of long bones to prevent serious complica- 
tions from arising. 

4. Early diagnosis, earl}'- reduction, and early immobilization of 
fractured vertebrae are the factors which comprise the ideal care of this 
type of injury. 

5. Delayed cord symptoms, following fractures of vertebrae as a 
result of hemorrhage, will, in a majority of cases, be eliminated by an early 
reduction of the fractiu-es. The mechanical reduction of the deformity 
will usually stop the hemorrhage and prevent delayed spinal-cord paralysis. 

6. The mobile hyperextension stretcher frame is so designed and 
constructed that the patient is moved onl}'- once, making it unnecessary to 
move him again to make the diagnosis, to reduce the fracture, and to im- 
mobilize the fracture. 


THE JOL'R.VAI. OF BONE AN'O JOINT 


.^i?Rc:iatv 




PATRIK HAGLUND 


May 27, ISTO-December S, 1037 

Patrik Haglund died suddenly on December S, 1937, in an attack of angina pectoris, 
having been occupied earlier in the day with his daily routine of work. 

Prof. Haglund was born in XorrkOping, Sweden, on May 27, 1S70, and began his 
career by taking a university degree in astronomy and phj'sics. He then transferred to 
the medical faculty, where ho received the degrees of Licentiate in Medicine in ISOO and 
Doctor of Medicine in 1003. He became a lecturer in Orthopaedic Surgery at the 
Caroline Institute in Stockholm and was elected Profes.sor of Orthopaedic Surgcr>' in 
1013, in which capacity he remained until 103.5 when he retired as an Honomry Professor. 

Prof. Haglund received his surgical training with Prof. Ivarl Gu=tav lyennander, the 
famous I'pjisala surgeon. In him Prof. Ix-nnander found a pupil who, with his niechaii- 
ic.al inclination and